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43–054 2009

HUMAN RESOURCES CHALLENGES WITH 

THE VETERANS HEALTH ADMINISTRATION 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

MAY 22, 2008 

Serial No. 110–88 

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 

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 

STEVE SCALISE, Louisiana 

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 

HENRY E. BROWN, JR., South Carolina 

VACANT 

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 

May 22, 2008 

Page 

Human Resources Challenges with the Veterans Health Administration ......... 1 

OPENING STATEMENTS 

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

Prepared statement of Chairman Michaud .................................................... 33 

Hon. Jeff Miller, Ranking Republican Member ..................................................... 2 

Prepared statement of Congressman Miller ................................................... 33 

Hon. Phil Hare ......................................................................................................... 2 

WITNESSES 

U.S. Department of Veterans Affairs, Joleen Clark, Chief Officer, Workforce 

Management and Consulting, Veterans Health Administration ..................... 26 

Prepared statement Ms. Clark ........................................................................ 56 

American Association of Nurse Anesthetists, Angela Mund, CRNA, MS, Clinical Director, University of Minnesota Nurse Anesthesia Area of Study, 

Minneapolis Veterans Affairs Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs ......................................................... 6 

Prepared statement of Ms. Mund ................................................................... 42 

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

RN, National Secretary-Treasurer ...................................................................... 3 

Prepared statement Mr. Cox ........................................................................... 34 

American Psychological Association, Randy Phelps, Ph.D., Deputy Executive 

Director for Professional Practice ....................................................................... 4 

Prepared statement of Dr. Phelps ................................................................... 38 

Disabled American Veterans, Adrian M. Atizado, Assistant National Legislative Director .......................................................................................................... 19 

Prepared statement of Mr. Atizado ................................................................. 54 

Paralyzed Veterans of America, Fred Cowell, Senior Associate Director for 

Health Analysis .................................................................................................... 16 

Prepared statement of Mr. Cowell .................................................................. 48 

Nurses Organization of Veterans Affairs, Cecilia McVey, BSN, MHA, RN, 

Immediate Past President, and Associate Director for Patient Care/Nursing, 

Veterans Affairs Boston Healthcare System, Veterans Health Administration, U.S. Department of Veterans Affairs ......................................................... 18 

Prepared statement of Ms. McVey .................................................................. 52 

Vertical Alliance Group, Inc., Texarkana, TX, Jay W. Wommack, Founder, 

President and Chief Executive Officer ............................................................... 8 

Prepared statement of Mr. Wommack ............................................................ 46 

MATERIAL SUBMITTED FOR THE RECORD 

Post Hearing Questions and Responses for the Record: 

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs, to Hon. James B. Peake, M.D., Secretary, 

U.S. Department of Veterans Affairs, letter dated June 5, 2008, including questions from Hon. Vic Snyder, and VA responses ........................... 60 


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HUMAN RESOURCES CHALLENGES WITH THE 

VETERANS HEALTH ADMINISTRATION 

THURSDAY, MAY 22, 2008 

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

The Subcommittee met, pursuant to notice, at 10:05 a.m., in 

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

[Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Snyder, Hare, and Miller. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

Mr. MICHAUD. The hearing will come to order, and I will ask the 

first panel to come forward. 

I would like to thank everyone for coming today. 

The Veterans Health Administration’s (VHA’s) mission is to provide patient-centered healthcare that is comparable to or better 

than care available in the non-U.S. Department of Veterans Affairs 

(VA) sector. To do this, VHA must have a viable healthcare workforce that is competent, well-trained and happy. 

Over the past 5 years, the VA has built a reputation of delivering 

healthcare efficiently and effectively. VA has been touted as the 

‘‘best care anywhere,’’ and the Department has been recognized on 

numerous occasions for healthcare quality and patient satisfaction. 

However, in order to carry that banner forward, careful planning 

and efficient processes must be put into the system to ensure continued success. 

We know that VA’s workforce is aging, with an average age of 

48.6 years. We know that at the end of 2012 a significant percentage of the employees will be eligible to retire. 

This Subcommittee has held many hearings that have examined 

the appropriateness and quality of care and treatment that veterans receive within the healthcare system. This hearing today will 

focus on the human resource challenges that VHA must address in 

order to ensure that there will not be a gap in expertise and quality of care provided to our veterans. 

The Subcommittee realizes that this is a complex issue, but we 

also recognize that it is an important one that deserves serious 

thought and consideration as well. 

I would like to recognize Mr. Miller for any opening statement 

that he might have. 

[The prepared statement of Chairman Michaud appears on 

p. 33.] 


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OPENING STATEMENT OF HON. JEFF MILLER 

Mr. MILLER. Thank you very much, Mr. Chairman. I do appreciate you holding this hearing today to examine all those challenges the VA faces in regards to keeping the high-quality 

healthcare workers that are currently in the system. They are on 

the frontline of the healthcare issue every single day. 

Our servicemembers who have honorably served our country deserve high-quality healthcare, and we must do what we can to keep 

those professionals retained and recruit them as well. One of the 

most pressing problems we face as a Nation is a marked shortage 

in virtually all areas of the healthcare worker industry, including 

nurses, physicians, physicians’ assistants, psychologists, pharmacists, and physical and occupational therapists. 

The VA system has been recognized for the significant benefit of 

its use of electronic medical records and focus on preventative care. 

To make sure that our veterans continue to receive the best care, 

it is critical that we see the VA as a workplace of choice. So I appreciate you putting this hearing together to focus and see what we 

can do better. 

I yield back the balance of my time. 

[The prepared statement of Congressman Miller appears on 

p. 33.] 

Mr. MICHAUD. Thank you. 

Mr. Hare. 

OPENING STATEMENT OF HON. PHIL HARE 

Mr. HARE. Thank you, Mr. Chairman. I want to thank you and 

Ranking Member Miller for holding this hearing today. 

The Veterans Health Administration is one of the most impressive healthcare delivery systems in the entire world, and that is in 

large part due to the dedicated medical professionals who make up 

the system. From doctors to nurses to technicians to psychologists, 

these are the men and women who are on the ground every day 

taking care of our Nation’s veterans. 

The veterans population will undergo significant changes over 

the next two decades. And as such, the leadership at the VHA will 

have to be prepared to handle these challenges. 

One of the biggest challenges is the recruitment and retention of 

highly qualified medical personnel at a time when the overall 

health industry is facing massive shortages. The VA must be able 

to compete with the private sector for medical staff. And we must 

ensure that, as the VHA continues forward, that they have the 

tools and the funds necessary to guarantee adequate numbers of 

staff in order to continue the care of our veterans. 

Once again, Mr. Chairman, I want to thank you for holding the 

hearing today. I look forward to hearing from our panels. And 

thank you very much, Mr. Chairman. I yield back. 

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

Our first panel includes David Cox, a Registered Nurse (RN) who 

is the National Secretary-Treasurer for American Federation of 

Government Employees (AFGE) of the AFL-CIO. 

I want to welcome you, David, here this morning. 

And Dr. Randy Phelps, who is the Deputy Executive Director of 

the American Psychological Association (APA); and Angela Mund, 


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who is a CRNA, the Clinical Director for Minneapolis VA Medical 

Center, who is here on behalf of the American Association of Nurse 

Anesthetists (AANA); and then Jay Wommack, President of 

Vertical Alliance Group, Inc. 

So I want to welcome our four panelists this morning and am 

looking forward to hearing your testimony. 

We will start off with Mr. Cox. 

STATEMENTS OF J. DAVID COX, RN, NATIONAL SECRETARYTREASURER, AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO; RANDY PHELPS, PH.D., DEPUTY EXECUTIVE DIRECTOR FOR PROFESSIONAL PRACTICE, AMERICAN 

PSYCHOLOGICAL ASSOCIATION; ANGELA MUND, CRNA, MS, 

CLINICAL DIRECTOR, UNIVERSITY OF MINNESOTA NURSE 

ANESTHESIA AREA OF STUDY, MINNEAPOLIS VETERANS AFFAIRS MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, ON BEHALF OF AMERICAN ASSOCIATION OF NURSE ANESTHETISTS; AND JAY W. WOMMACK, FOUNDER, PRESIDENT 

AND CHIEF EXECUTIVE OFFICER, VERTICAL ALLIANCE 

GROUP, INC., TEXARKANA, TX 

STATEMENT OF J. DAVID COX 

Mr. COX. Chairman Michaud and Ranking Member Miller and 

distinguished Members of the Subcommittee—it seems like I am 

getting off to a bad start here. I am tying my tongue up this morning. I have never been first on a panel; maybe that is what it is. 

Thank you for the opportunity to testify today. AFGE greatly appreciates the Subcommittee’s continued attention to the impact of 

VA healthcare workforce problems on patient care. 

Veterans want to get their care from the VA because VA 

healthcare professionals are extremely dedicated to their patients 

and committed to the mission of the VA. In the eighties, labor management collaboration helped transform the VA into a healthcare 

leader in best practices, patient safety and healthcare information 

technology. 

AFGE believes the greatest human resources challenge facing 

VHA today is the continuing erosion of title 38 collective bargaining rights, as I will discuss shortly. First, I would like to address several other human resources issues of concern to AFGE. 

The hybrid title 38 process, which covers psychologists, social 

workers, pharmacists and licensed practical nurses (LPNs), among 

others, has become severely backlogged. It is also troubling that 

VHA employees lose their veterans’ preference when they are converted to title 38 from title 5. 

Therefore, AFGE urges this Subcommittee to reject proposals to 

add more positions to title 38 and instead conduct a pilot project 

using a streamlined title 5 hiring process to compare the two systems. We would be pleased to work with you to develop this pilot 

project and believe it can provide valuable lessons for other Federal 

employers. 

AFGE also urges the Subcommittee to conduct oversight into the 

many implementation problems surrounding the 2004 physician 

pay law, such as secretive process for setting market pay and use 


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of improper performance measures. Since Congress is still waiting 

for the VA’s long-overdue report on how well the pay law is working and whether it is has reduced the VA’s reliance on costly contract physicians, we urge the Subcommittee to conduct its own 

study on this important law instead. 

Nurse alternative work schedules provide full-time pay for working 3 12-hour days per week or 9 months per year. These schedules 

are very popular in the private sector and could be a valuable VHA 

recruitment and retention tool. Unfortunately, VHA refuses to offer 

this schedule option to its nurses, even though they were given this 

authority by Congress 4 years ago. AFGE recommends that Congress amend the law to require the VA to offer alternate work 

schedules based on a fixed formula that aligns facilities with their 

local labor markets. 

Turning to title 38 collective bargaining rights, we are very 

grateful to Chairman Michaud and Subcommittee Members Berkley, Brown and Doyle for cosponsoring H.R. 4089. This bill is an 

essential enforcement tool for past and future VHA recruitment 

and retention legislation. 

In 1991, Congress provided RNs, physicians and other pure title 

38 providers with rights to challenge improper personnel policies 

through grievances, arbitrations and the court. Providers lost these 

rights because the VA began using an arbitrary interpretation of 

the three exceptions in section 7422 of title 38: professional conduct 

and competency, peer review, and compensation. 

Management’s section 7422 policy directly contradicts Congressional intent, as is evident by the plain language of the law and 

the legislative history. Management’s section 7422 policy is also inconsistent with its own position that it took in 1996 with a labor 

management agreement to allow grievances over indirect patient 

care matters, scheduling, and rights to pay survey data. 

The VA contends that amending section 7422 will allow labor to 

disrupt patient care. But management’s rights to determine the 

agency’s mission under title 5 already protect against that. And the 

VA cannot point to a single case where a grievance involved a challenge to medical procedures. VHA employees who have full grievance rights, such as LPNs, psychologists, and pharmacists, never 

use these rights to disrupt patient care. 

The VA also contends that current law gives title 38 providers 

fair process for deciding when a grievance can be filed, pointing to 

a review by the Under Secretary for Health. We asked, fair to 

whom? In the past 3 years, 100 percent of these decisions have 

been in favor of management. Shouldn’t VA healthcare dollars be 

spent on caring for veterans, not looking for ways to block legitimate concerns of hard-working, dedicated nurses and physicians? 

Thank you, Mr. Chairman. I would be glad to entertain any 

questions from the Committee. 

[The prepared statement of Mr. Cox appears on p. 34.] 

Mr. MICHAUD. Thank you very much. 

Doctor. 

STATEMENT OF RANDY PHELPS, PH.D. 

Dr. PHELPS. Thank you, Mr. Chairman, Ranking Member Miller 

and distinguished Members of the Subcommittee. I am Dr. Randy 


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Phelps, Deputy Executive Director for Professional Practice of the 

American Psychological Association. 

We are the largest association of psychologists, with approximately 90,000 full doctoral psychology members and another 

50,000 graduate students in the pipeline. Our folks are engaged in 

the study, research and practice of psychology. 

I am currently a licensed clinical psychologist but formerly a 

practitioner myself, a clinical researcher and educator. And for the 

last 15 years, I have been on the APA Executive Staff and have 

served as APA’s liaison to Professional Psychology in the Department of Veterans Affairs. 

We really appreciate the opportunity to testify today about 

human resources challenges within VHA. 

I should note at the outset that VHA is the workplace of choice 

for many of our members. There are over 2,400 psychologists working nationwide in the system. And, in fact, VA is the largest single 

employer of psychologists in this country. 

Professional psychology was born as a result of the needs of returning soldiers from previous wars, particularly World War II. So 

we owe a great debt to the brave men and women who have served 

this country. 

I will shorten the remarks, obviously, for the oral testimony. 

There is a considerable amount of detail in the written testimony. 

But psychologists are very actively involved, particularly in the 

mental health side, of treatment of veterans in VA. The architects 

of the two evidence-based practice treatments for post traumatic 

stress disorder (PTSD) are psychologists. Psychologists are serving 

a very critical role in understanding diagnosis and treatment of 

traumatic brain injury (TBI), which is the other signature wound 

of the war, alongside nursing, neurologists and other folks. 

Recruitment of psychologists in the VA is actually in a good place 

at this point. It has not been until the last year and a half. And 

we applaud VHA’s efforts to add 800 new positions for doctoral psychologists since 2005, bringing us up to that 2,400 psychologists in 

the system. Most of those folks, I should add, are young psychologists entering the system at GS–11. 

I should emphasize that every psychologist who comes out of a 

clinical or counseling program already knows how to treat PTSD, 

depression and so forth. 

The thing that I wanted to emphasize, though, about recruitment 

is that the staffing levels are a very recent developments. It was 

only 2 years ago where we reached the staffing levels of psychologists in the VA of the 1995 years. So the curve has been going 

down until just very recently with the hiring of this new cadre of 

psychologists. 

Additionally—and this gets to the issue of retention that I would 

like to spend a little bit more time on—additionally, the number of 

GS–14 and GS–15 psychologists in the system at the higher leadership levels are actually not increasing similarly. The GS–15 level 

is lower than it was in 1995. 

The VA has done a good job of recruiting new psychologists coming into the system because it is hiring its own. We have approximately 600 psychology training positions within VA, and 75 percent of the new hires are past VA psychology trainees. 


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There are three major problems, however, that affect retention of 

the workforce that I can elaborate on later if you have questions. 

One is a lack of uniform psychology leadership positions. We are 

the only mental health position without an officially designated 

leader at medical centers. There is a very inequitable access to key 

leadership positions throughout VA. And there are, as you have 

heard some from a colleague, very serious implementation issues 

with the hybrid title 38. In fact, I would describe the implementation of the hybrid title 38 system as an absolute boondoggle, bureaucratically and otherwise, for the system. 

These problems—which, again, we can elaborate on later—have 

led to a number of very chilling situations for psychologists 

throughout the country, where folks are leaving the VA to go to the 

private sector, losing their positions, inability to get advancement 

and so forth. 

And we consider those kinds of problems as the most serious obstacles to making VA the workplace of choice for psychologists now 

and in the future, because without clear advancement systems in 

place, VA faces critical long-term recruitment and retention problems. As psychologists come to believe that there is little possibility 

for advancement in the system, regardless of the level of complexity of their responsibilities, fewer VA psychologists will be willing to accept positions of greater responsibility. 

And, in addition, high-potential trainees coming into the system 

the VA would like to recruit for the future will increasingly, and 

are increasingly, seeing VA as a dead-end for their careers and will 

be attracted to other career options with more potential for advancement. 

And we thank you very much for this opportunity to testify 

today. Thank you. 

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

Mr. MICHAUD. Thank you. 

Ms. Mund. 

STATEMENT OF ANGELA MUND, CRNA, MS 

Ms. MUND. Chairman Michaud, Ranking Member Miller and 

Members of the Subcommittee, good morning. My name is Angela 

Mund. I am a Certified Registered Nurse Anesthetist, or a CRNA, 

at the Minneapolis VA. I also serve as President of the Association 

of VA Nurse Anesthetists. And I am pleased to appear before you 

on behalf of my profession, the American Association of Nurse Anesthetists and its 39,000 members in the United States. 

You have my written statement, and I ask unanimous consent 

for it to be entered into the record. 

Mr. MICHAUD. Without objection. 

Ms. MUND. America’s CRNAs provide some 30 million anesthetics annually in every healthcare setting requiring anesthesia 

care, and we provide that safely. The Institute of Medicine reported 

in 2000 that anesthesia is 50 times safer now than it was in the 

1980s. For over 125 years, nurse anesthetists have met the mission 

of caring for our veterans, caring for those who have borne the battle, their widows and orphans. 

Nurse anesthetists are the predominant provider of anesthesia 

services in the VA and are the sole anesthesia provider in 12 perVerDate Nov 24 2008 00:45 Mar 10, 2009 Jkt 043054 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 E:\HR\OC\43054.XXX 43054

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cent of VA facilities. In the days before I left for this hearing, I personally provided anesthesia for our veterans. Any of the more than 

500 CRNAs in the Veterans Health Administration could say the 

same. 

But the average VA CRNA is 53 years old, 7 years older than 

the profession’s average, and is approaching retirement. In any recent year, nearly one in five VA CRNAs leaves or retires from the 

VA. Twenty-four VA facilities report CRNA vacancies. We believe 

that actual number is closer to 40, and the U.S. Government Accountability Office (GAO), in their report, used 70 as the number. 

Contract personnel also fill about 150 of the VA CRNA posts. 

We are increasingly concerned that without a sufficient number 

of CRNAs in the VA system, our veterans won’t get the care they 

need and deserve. They may have to wait too long for that care, 

which ultimately may increase cost to the U.S. Treasury. 

A report last December from the GAO confirmed what we, in the 

VA, have long known. The GAO found 54 percent of VA facilities 

have had to close operating rooms, and 74 percent have had to 

delay surgeries for lack of CRNAs. Twenty-six percent of VA 

CRNAs plan to retire within the next 5 years, and the agency has 

struggled to both recruit and retain nurse anesthetists. Seventyfour percent of VA respondents to the GAO survey said they had 

difficulty recruiting CRNAs. 

The VA’s struggle has not been for lack of CRNAs in the marketplace. In 2007, accredited nurse anesthesia educational programs 

produced over 2,000 graduates, an 88 percent increase in just 5 

years, in order to meet the growing demand for anesthesia services. 

Rather, the GAO found, and we agree, that the VA CRNA compensation is far below market levels in many localities. 

The issue of below-market compensation was cited by 90 percent 

of chief anesthesiologists reporting difficulty recruiting CRNAs and 

by 77 percent of chief anesthesiologists reporting difficulty retaining CRNAs. In some facilities, bad working conditions also sent 

good CRNAs elsewhere. 

We have three recommendations to close this gap and to ensure 

American veterans have the necessary anesthesia care for the surgical and invasive diagnostic procedures they require. 

First is to enhance the VA relationship with the nurse anesthesia 

educational programs. Already some 70 VA hospitals serve as clinical practice education sites for nurse anesthesia schools. Many 

hospitals find serving these clinical practice sites helps them recruit new CRNAs. 

Second is to continue nurturing the VA’s joint relationship with 

the U.S. Army Nurse anesthesia educational program at Fort Sam 

Houston, Texas, which educates CRNAs for VA service. The current program uses the VA Employee Incentive Scholarship Program, or EISP, to fund tuition, fees and salary reimbursement for 

nurse anesthesia students who then fulfill a service commitment to 

the VA. 

Third is to bring VA’s CRNA compensation closer to local market 

rates. The GAO recommends VA facilities take advantage of VA locality pay policies. But that will not be enough to close the gap. In 

addition, Congress should act to lift the statutory cap on VA CRNA 


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pay so that local facilities can set compensation at rates closer to 

market levels. 

Of all the options available to close the VA’s CRNA workforce 

gap and ensure veterans gets the high quality of care they deserve, 

these three suggestions are the most cost-effective and the easiest 

to carry out. 

Thank you, and I would be happy to take your questions. 

[The prepared statement of Ms. Mund appears on p. 42.] 

Mr. MICHAUD. Thank you very much. 

Mr. Wommack. 

STATEMENT OF JAY W. WOMMACK 

Mr. WOMMACK. I would like to start with a quote. ‘‘In times of 

change, learners inherit the Earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists’’—Eric Hoffer. 

I don’t need to repeat the nursing shortage; everybody up here 

knows that. The baby boomers are about to retire. We, 2 years ago, 

entered the first baby boomer turning age 60. This year, the first 

baby boomer started to retire at 62. And this generation looks like 

a basketball going through the belly of a snake, and behind it we 

do not have enough people to fill the needs in the healthcare industry. 

On top of that, we have a declining dollar. A declining dollar 

causes devaluation of the currency, which means the Canadian dollar is more powerful. We are seeing nurses leave the United States, 

to go back up north. 

We see all these things and we see the nursing shortage is in 

quite a state, but I think there is a worse shortage than that out 

there, and the worst shortage is the shortage of qualified, welltrained, recruiting personnel, not just to recruit nurses and medical 

personnel, but also to go out and actively recruit people to teach 

in the schools, because we are short on educators. We had to turn 

down 38,000-plus, in the last few years, going to schools to learn 

how to be medical personnel. 

Each month, millions of dollars are spent on advertising to draw 

people into not just the private sector, but into the public sector, 

both sectors, to draw them into the medical community, to recruit 

them for institutions. Millions of dollars are spent to generate leads 

and phone calls. And guess what happens? We have dealt with the 

private sector, and 82 percent of the phone calls for people that 

would like to have jobs go unanswered. I cannot speak for the VA 

system; I haven’t worked with them. But in the private sector, that 

is an astounding number, and that number is shocking. 

Mr. Chairman, Members of Subcommittee, my name is Jay 

Wommack. I am the Chief Executive Officer of a company called 

Vertical Alliance Group. We are an Internet-based training, recruiting company. We were founded in 1999. We have 80 Web sites, 

sub-domains and domains, of which a couple of them represent the 

medical community, one called NurseUniverse, one called 

MedVotech. Obviously, the names imply they are out to recruit 

nurses and people for the medical vo-tech schools. We operate those 

Web sites. 


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And I have to tell you, I am honored to be here to make this 

presentation. It is a wonderful experience and wonderful opportunity, and I appreciate you all taking the time to hear us and our 

testimony. 

I don’t make any claim to be a professional in the healthcare 

services area. However, we do know quite a bit. In the last 9 years, 

we have developed quite a bit about the process of recruiting and 

retaining good employees. Now, we do this with boot camps. And 

let me address that issue real quick. 

There is a dire lack of training for people that know how to go 

out and deal with the society today. The Internet changed everything. It made us an immediate-gratification society. Things happen fast. I mean, when I go to Amazon and I go and order a book, 

I want it, I want it now. I don’t like waiting till tomorrow. And this 

is how people are when they are looking for jobs. They go fill out 

an application or make a phone call. These people are hanging up 

before 1 minute when no one is answering the telephone. They are 

sending in applications, and you have seen the medical applications. It takes time to fill out an application. They send those in, 

and they get no response. 

So what we did as a company is we started to develop processes 

that basically said we are going to train people from being paper 

processors, the old style of human resource, into active, proactive 

salespeople. Because that is what it takes to compete in this environment. 

We train them to be salespeople through our boot camps. We empower people and teach the salespeople—we call them salespeople—we teach them sales training. We teach them direct-response marketing. We teach them what it costs to actually recruit 

a nurse. Many people don’t know. Advertising cost per hire is 

$10,000 to recruit a nurse, according to AMA. It costs between 

$35,000 and $70,000 to recruit a nurse, not to mention a nurse anesthetist. So we are training these people, we are empowering 

them, teaching them what it takes to go out and be a proactive recruiter. 

Have we had success? The standard average of a recruiting department gets between 1 and 2 percent closing on the people that 

apply for a job. Our companies, on a bell curve, at the top of it, get 

an average of 12 percent closing. Some, obviously, have gotten 

much more than that, some less, but on the average, on the bell 

curve. That is significant savings to the bottom line. The process 

lends itself to the lowest cost per hire. 

But you have to inspect what you train, and you have to continue 

to teach what you train. So we developed a process, an online, 

Internet, databased program that basically teaches, tracks, trains 

and follows up on all the education we provide at the boot camps. 

We do it daily, weekly, monthly. It is available 24/7. 

It doesn’t just happen, though. In order for a program to be successful, it must have buy-in from the top. Obviously, we wouldn’t 

be sitting here if there wasn’t buy-in from the top. 

I visit with a number of VA healthcare facilities. The executives 

at those facilities, they absolutely care. They would like to push 

forward, and they have put together great programs, but they like 

to push forward and get their hiring in order. 


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I am excited to be here. I appreciate the opportunity to speak, 

and I will be glad to answer any questions. 

[The prepared statement of Mr. Wommack appears on p. 46.] 

Mr. MICHAUD. Thank you very much. I appreciate it. 

My first question will be for Mr. Cox. 

You talked about H.R. 4089, the bill that is pending. If that is 

passed, what impact will that really have on recruitment and retention, in your opinion? 

Mr. COX. We believe that it would give the registered nurses and 

physicians the same rights that other employees have in the VA; 

that if there are workplace disputes, that they would have an avenue to resolve those disputes and to seek relief in that arena. 

It is a message we hear from our membership and the VA employees over and over, and we believe that it would certainly make 

for a better workplace. 

Mr. MICHAUD. But as far as the recruitment or retention, do you 

think it will have a positive effect? 

Mr. COX. I think it will definitely have a positive effect on the 

recruitment and retention, because, again, when you are able to resolve problems in the workplace through a negotiated agreement to 

resolve those issues, that makes people feel better. There is a way 

to seek relief if you believe things are wrong. 

I believe, also, the fact that the pay data, that we have all the 

locality pay systems, but now if a request is made to the VA, 

‘‘Share this data with us, show us what you are paying, give us information,’’ it is, ‘‘No, we do not have to provide that to you, because that is a section 7422 issue.’’ I believe it would bring more 

light to the issue of pay and the recruitment process. But it would 

definitely be a positive impact. 

Mr. MICHAUD. Thank you. 

Dr. Phelps, you had mentioned the impact of the hybrid title 38. 

What impact would moving psychologists to title 38 from the hybrid title 38 have on recruitment and retention of these professionals? 

Dr. PHELPS. Mr. Chairman, that is an issue that we are—because 

we are so frustrated with the difficulties and the implementation 

problems with the hybrid system, that is an issue that we are looking at very seriously right now. 

Preliminarily, we think it would be the way to go for psychologists. We are the only doctoral-level professionals in the VA system 

that are not in the title 38 system. So we are very much in favor 

of that direction. 

Mr. MICHAUD. Thank you. 

Ms. Mund, how many CRNA candidates rotate through the 70 

VA training sites annually? 

And my second question is, out of that, how many of those candidates actually choose the VA upon completion of their training? 

Ms. MUND. I don’t have those numbers with me, but I can have 

my staff look at that. 

However, what I can speak to is—I am clinical director of a 

nurse anesthesia program through the University of Minnesota. 

And the VA in Minneapolis is our primary clinical site. We have 

had a relationship with them 25 years, I believe, recently. And we 

send 10 students per year through the VA. We get some support 


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from Central Office, which we appreciate. In previous years, as 

much as 75 percent of the graduating class have stayed at the VA. 

However, in the last 2 years, we have had one person out of 20. 

And a lot of that is due to low pay, is the main thing. I mean, 

they come out with student loans and are unable to have a salary 

that makes it easier to pay those student loans off. 

And the other big piece of it is the employee debt-reduction program that the VA has, it is not entirely, through issues with 

human resources, lack of understanding of the program. Not everybody who has been eligible has been able to take advantage of that 

as a student loan payback. So they have chosen to go to places 

where they can see exactly, when they apply, HR can tell them, 

‘‘This is what you will make, this is what we will give you, and this 

is what your loan payback is.’’ The VA is a little bit hazy on that, 

so students elect to go elsewhere. 

Mr. MICHAUD. I believe it was in your written testimony, you rec- ommended $400,000 in fiscal year 2009 appropriations to expand 

the joint education program. How many additional CRNAs would 

this funding affect? 

Ms. MUND. What they have right now is they have had seven 

graduates and are working. They have three who are in what we 

call phase II, which a clinical portion, three that are in the firstyear portion, and three that are starting. 

I believe that they would like to increase that number, and the 

Army is available with slots, with seats for those, but they need additional funding to have the students come. 

The benefit of going there is that you get your tuition, salary and 

your education paid for. And then they have a three-year commitment after completing the program. 

Mr. MICHAUD. Thank you. 

My last question is for Mr. Wommack. 

What immediate action should the VA take to modernize their 

hiring system so that it is competitive with the private sector? 

Mr. WOMMACK. That is a very good question. 

The first thing I would do is I would start training the personnel 

on being very proactive. You have to train these people. They have 

the tools in place. The VA has done a great job of putting together 

a package of information, kits like that. But they have to be 

brought into the 21st century via the technology, the platforms of 

technology that they have at their disposal and that we offer. 

They have to be trained, and they have to be trained in the value 

of what they are doing, the lead. The half-life of a lead, when someone picks up that phone to call or when someone sends in an application, the half-life of that lead is probably less than 4 hours. In 

other words, if you don’t touch it in 4 hours, they are gone. That 

is what we found; it may be even shorter than that. 

So the first thing I would do is set up training for them. And 

then you have to follow up and monitor exactly what you have 

taught. You have to inspect it every single week. We do that with 

our existing clients. We train them, and then we follow up every 

single week, and we make them respond to us, because that is 

where you ferret out what the real problems are. You find out what 

is working, what is not working, and then you adjust it and you 

change it. And then you continue the education process. 


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Mr. MICHAUD. Great. Thank you. 

Mr. Miller. 

Mr. MILLER. Thank you, Mr. Chairman. 

Mr. Cox, can you give me a little feel for the difference between 

title 5 and title 38 in regards to the hiring process? How would 

title 5 be more or less stringent than title 38? 

Mr. COX. Title 5 employees get on registers. They go through, as 

you know, the various places throughout the country. They apply 

with USAJOBS, those type things. They get on registries. They are 

hired. From that, they get veterans’ preference, things of that nature. 

Title 38, like registered nurses and physicians, they can go to a 

VA medical center, fill out an application and be hired. There is a 

boarding process that title 38s have to go through, the 

credentialing process, things of that nature, which takes a very 

lengthy period of time. And that is what really holds up a lot of 

the hiring process at the VA in the title 38 arena. 

With the hybrid title 38s, again, the VA has not developed a lot 

of the qualification standards, so there is not the boarding processes to promote these people and to move them through the proper grades. It is a very, very complex hiring system. 

Mr. MILLER. Well, you recommended establishing a pilot program 

streamlining title 5. I would like to know a little more in detail 

about, what that plan would—or how it would differ from the current title 5? Wouldn’t it be just as useful to streamline or do a pilot 

program to streamline the hybrid title 38 hiring process? 

Mr. COX. We believe that you can go to Office of Personnel Management (OPM) and the agency, VA, can work with OPM, do a 

demonstration project to—like, nursing assistants is one group 

that, if people are certified, that you could hire them through a 

title 5 process that would actually be easier than the hybrid title 

38. Because with that, you have to develop the qualification standards, the boards that would then have to evaluate the people, determine their promotions and appointments and things of that nature. 

So we believe that there are procedures with OPM that could actually streamline title 5 and make it easier than hybrid title 38. 

And one thing that we believe that that would also help, it would 

maintain the veteran preference for the employees. 

Mr. MILLER. Give me a little indication of how the retirement 

benefits differ from the Federal worker and the private sector right 

now. 

Mr. COX. The difference in the retirement benefits? 

Mr. MILLER. Yes. 

Mr. COX. I am not sure that I could give you a total picture on 

that. 

Mr. MILLER. More, less, better, worse? 

Mr. COX. I retired from the Federal Government myself 2 years 

ago, and I have friends that are in the private sector. And I would 

say, with the current FERS employees, it is about comparable to 

the private sector. Most employees in the private sector have some 

type of matching 401(k) plan and some other defined benefit plan, 

such as—available with that. But I would say this, we’re fairly 

comparable in that arena. 


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And, in some areas, I believe the private-sector retirement may 

be better; in others, obviously, the Federal Government. I am not 

sure that I am—— 

Mr. MILLER. What about health insurance? 

Mr. COX. Health insurance, private sector, in many cases, is better than the Federal employee health insurance. 

Mr. MILLER. Dr. Phelps, what benefits do you see in bringing 

psychologists fully into the title 38 program? 

Dr. PHELPS. As I said, Mr. Miller, we are looking more closely 

at that. We have tried to be good citizens with the hybrid system. 

So the benefits would be to eliminate some of these kinds of problems with the hybrid system. 

Let me give you a couple of examples. As Mr. Cox said, that with 

the hybrid title 38 system there is required the creation of professional standards boards for each of those disciplines. Psychology 

has a national professional standards board, and it also has developed its quality standards. And so that process is under way. 

But what has been happening for the last year or so is that psychologists with additional scope of responsibility—running huge 

treatment programs, 60 psychology staff under them and so forth— 

who have submitted to the professional standard boards and have 

then been recommended nationally for a grade increase have then 

been stymied at the level of the local medical center, in most cases. 

Some cases, it is at division level. 

And the VA itself is issuing, in some cases certainly, informational missteps about who is qualified, who is not qualified, what 

do you have to submit and so forth. 

So moving into a system that is based on the title 38 system, 

that is based simply on the professional is hired, promoted and retained based solely on their qualifications, as opposed to going 

through these very complex processes that VA has been unable to 

implement over the past 5 years. It has been 5 years since the Congress changed the hybrid statutorily. 

So we believe that it would very much not only simplify the system for psychologists, but certainly improve the recruitment of new 

psychologists and, clearly, the retention of psychologists, the leadership. We have a lot of psychologists in the system who have been 

in 20 and 30 years that are operating at the GS–13 level. They are 

not there for the money. They are there because of the dedication 

to veterans. And they need to be the folks training the new cadre 

of professionals. 

Mr. MILLER. Thank you very much. 

I apologize to Ms. Mund and Mr. Wommack. My time for questions has expired. 

Mr. MICHAUD. Mr. Hare. 

Mr. HARE. Thank you, Mr. Chairman. 

Ms. Mund, I was wondering, could you please compare the differences between hiring, retention or educational benefits packages 

offered by the VA and the private sector for CRNAs? And does the 

VA excel in any of those areas more than the private sector? 

Ms. MUND. Well, the main difference, I think, between the two 

is other places, what I have heard from my students, especially recent grads, are they can call up the University of Minnesota hospital and say, ‘‘I am a new grad. What am I going to start at for 


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salary? What kind of bonus am I going to get? What can I see for 

loan paybacks?’’ And they can get that number from human resources immediately. 

The problem with the VA is often they will call human resources 

and they will get a range just like it is posted on VA Jobs. So the 

student does not know where they are starting until they sign on. 

Often they are not going to take that chance when the range is 

anywhere from $89,000 to $139,000. It is difficult to see where you 

would fit on that scale. 

The other thing is the employee debt-reduction program, which 

I spoke to before, which I think is a great recruitment tool. The 

problems is there is a 6-month window that, if you don’t apply for 

it within that time, you are no longer eligible. Well, if for some reason paperwork has been lost, the human resources person covering 

that student has some lack of information, all of a sudden that 6- 

month window is gone and the debt-reduction program they are no 

longer eligible for. Other things related to that is human resources 

also, if it does not say on the Web site that you are eligible for the 

Education Debt Reduction Program (EDRP), they cannot offer that 

to you once you sign on. 

So I think a lot of it is the transparency for when students apply 

for jobs. They need to see that in the VA. They need to know that 

these things are going to be available and rather than getting lost 

in the shuffle of paperwork and time. 

Mr. HARE. Because it would seem to me, somebody graduates 

and they know at one hospital what their bonus is going to be, 

their salary is going to be, their compensation is going to be, almost to the penny—— 

Ms. MUND. Right. 

Mr. HARE [continuing]. And then you have the VA who gives 

them a range. So if you are getting out of school with a lot of debt 

load, and I am sure the debt load is significant, it has got to really 

put us at a disadvantage, I am assuming. 

I can’t blame the student, I mean, obviously, because they have 

spent this time and, as I said, built up a lot of debt. 

Ms. MUND. And I think the unfortunate thing is they primarily 

had their training site in the VA, and they loved taking care of veterans. There really is not another population that is like that. But 

after having the time and expense of school, sometimes you have 

to weigh those things. And I think that if we did a better job of 

a transparent benefit package, I think the VA could be very comparable. 

Mr. HARE. Mr. Cox, can you talk a little bit more about the hybrid hiring process and what makes it so long and complicated for 

prospective applicants? 

Mr. COX. The hybrid—again, the VA has to develop qualification 

standards. The way that it is sold to everyone in the beginning is 

that, okay, hybrid, you can just walk in, fill out an application and 

apply for a job. That is fine; that process is simplified. But then 

there is the qualifications standards, the professional standards 

boards. These people have to be brought in. The boards have to 

meet. They have to review the qualifications of the people, then establish their grade, those type things. 


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That is what really complicates the process. While it is not the 

actual application process, it is the professional standards boards, 

the qualifications standards that create the problems in it. 

Mr. HARE. And my last question here. Dr. Phelps, outside of fair 

compensation, how else would uniformed leadership in the VA facilities benefit recruitment and retention of psychologists? 

Dr. PHELPS. The issue of uniformed leadership is this. In the 

mid-nineties, when Dr. Kaiser came in, regionalized the system, 

got rid of discipline-based services, what happened was, not just to 

psychology but with other professions as well, social work—I am 

most familiar with the mental health side—is we had staffs reporting to other disciplines who had no understanding of what the 

standards of practice are within that particular discipline. 

What has happened since then is a recognition by the system 

that the ability to certify the qualifications, the skill sets and so 

forth of psychologists in the system requires somebody in psychology. So we have a system where there is no uniformity. Facilities appoint a lead psychologist or a senior psychologist; there are 

many different terms. And this gets back to the issue of, sort of, 

fair pay for a fair day’s work, Mr. Hare. Those folks operate in 

those positions in addition to their regular job description. 

And part of our issue with the hybrid is national standards 

boards and the quality standards have recognized that those are 

additional responsibilities that should bring additional pay, but 

there is no uniformity even at the level of what those types of positions are. 

Mr. HARE. Thank you. 

Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you, Mr. Hare. 

Once again, I would like to thank our panelists. We will have 

some additional questions for the record, so if you could answer the 

questions for the record, we would appreciate it very much. Once 

again, thank each and every one of you for coming out this morning. 

Our second panel is comprised of Fred Cowell, who works for the 

Paralyzed Veterans of America (PVA); Adrian Atizado, of the Disabled American Veterans (DAV); and Cecilia McVey, who is the Associate Director of Patient Care and Nursing in the VA Boston 

Healthcare System, and Immediate Past President of the Nurses 

Organization of Veterans Affairs (NOVA). 

I would like to welcome our second panel. I am looking forward 

to your testimony here this morning. 

And we will start off with Mr. Cowell. 


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STATEMENTS OF FRED COWELL, SENIOR ASSOCIATE DIRECTOR FOR HEALTH ANALYSIS, PARALYZED VETERANS OF 

AMERICA; CECILIA MCVEY, BSN, MHA, RN, ASSOCIATE DIRECTOR FOR PATIENT CARE/NURSING, VETERANS AFFAIRS 

BOSTON HEALTHCARE SYSTEM, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND 

IMMEDIATE PAST PRESIDENT, NURSES ORGANIZATION OF 

VETERANS AFFAIRS; AND ADRIAN M. ATIZADO, ASSISTANT 

NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN 

VETERANS 

STATEMENT OF FRED COWELL 

Mr. COWELL. Chairman Michaud, Ranking Member Miller and 

Members of the Subcommittee, on behalf of the Paralyzed Veterans 

of America, I am pleased to offer our views concerning the human 

resource challenges within the Department of Veterans Affairs. 

Mr. Chairman, the Subcommittee’s interest in the issues concerning VA healthcare personnel is well-placed and timely. Congress must assist VA’s efforts to recruit and retain its corps of 

healthcare professionals as the demand for healthcare increases because of today’s wars and the aging of veteran population from previous wars. 

Currently, the Nation is experiencing serious shortfalls in its 

supply of physicians, nurses, pharmacists, therapists and psychologists. Competition for experienced medical personnel and newly licensed professionals is keen. 

PVA believes that Congress must take the lead in revamping 

outdated personnel policies and procedures, that includes salaries, 

benefits and working conditions, that may place VA at a disadvantage in today’s labor market and will prevent VA from becoming a 

medical care employer of choice in the future. 

PVA also believes that the broken VA appropriation process, 

which delays VA funding, is a major barrier to VA’s healthcare professional recruitment processes. 

VA nurse recruitment and retention efforts: As has been stated 

earlier, the United States is currently in the 10th year of a critical 

nursing shortage which is expected to continue through 2020. The 

current and emerging gap between the supply of and the demand 

for nurses may adversely affect the VA’s ability to meet the 

healthcare needs of those who have served our Nation. 

The VA must be able to recruit the best nurses and retain a 

cadre of experienced, competent nurses. Providing high-quality 

nursing care to the Nation’s veterans is integral to VA’s healthcare 

mission. 

VA physician recruitment and retention: PVA is concerned about 

VA’s current ability to maintain appropriate and adequate levels of 

physician staffing at a time when the Nation faces a pending shortage of physicians. Recent analysis by the Association of American 

Medical Colleges indicates the United States will face a serious 

doctor shortage over the next few decades. The subsequent increasing demand for doctors as many enter retirement will increase 

challenges to VA’s recruitment and the retention efforts. 

VA’s psychologist recruitment, retention and appropriate promotions: According to the American Psychological Association, VA 


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is the largest single employer of psychologists in the Nation. Congress and VA have recognized the need to increase the number of 

psychologists and have added more than 800 new psychologists 

since 2005, thereby raising the number of the psychologists in the 

VA system to approximately 2,400. 

VA must also strive to retain and promote its more experienced 

psychologists in order to meet new training and supervision requirements. Since the vast majority of new psychologist hires in VA 

are less experienced professionals, VA must ensure they are properly trained and supervised. VA must also strive to retain and promote its more experienced psychologists in order to meet new training and supervision requirements. 

Recommendations to enhance VA’s recruitment retention efforts: 

Congress must revamp outdated VA personnel policies and procedures to streamline the VA hiring process and avoid recruitment 

delays that become barriers to employment. 

Conduct Congressional oversight hearings to determine the extent of problems regarding national standardization and availability of VA locality pay. 

Congress should implement a title 38 specialty pay provision for 

VA nurses providing care in VA specialized service areas, such as 

spinal cord injury, blind rehabilitation, mental health, and traumatic brain injury. 

Review and adopt the recommendations developed by the VA’s 

National Commission on VA Nursing. PVA believes these recommendations have broad application and can serve as a template 

for improvements that can assist VA’s human resource management recruitment and retention efforts. 

Congress should improve the provisions of VA’s Education Debt 

Reduction Program, the EDRP. Currently, the EDRP is limited to 

not more than $49,000 spread out over 5 years of service. This program has not kept pace with the soaring costs of medical specialty 

education. Expanding benefit levels in EDRP will make VA more 

competitive than the national healthcare professional marketplace. 

VA must also become more flexible with its work schedules to 

meet the needs of today’s healthcare professionals. 

Other benefits, such as child care, and a less stringent policy regarding mandatory overtime will make VA employment more attractive. 

Congress should also consider reinstating the VA Health Professional Education Assistance Scholarship Program. This program 

was sunset in 1998, and the program would be an excellent medical 

care student incentive to future VA employment. 

Finally, Mr. Chairman, PVA believes that Congress must find a 

solution to delays with the VA appropriation process. Delays in VA 

appropriations hamstring VA managers’ recruitment efforts all 

across the country. 

Mr. Chairman, this concludes my remarks. I will be happy to answer any questions you may have. 

[The prepared statement of Mr. Cowell appears on p. 48.] 

Mr. MICHAUD. Thank you very much. 

Ms. McVey. 


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STATEMENT OF CECILIA MCVEY, BSN, MHA, RN 

Ms. MCVEY. Mr. Chairman and Members of the Committee on 

Veterans Affairs’ Subcommittee on Health, the Nurses Organization of Veterans Affairs, NOVA, would like to thank you for inviting us to present testimony on human resource issues in VA. 

I am Cecilia McVey, Associate Director for Patient Care/Nursing 

at the VA Boston Healthcare System, and I am here today as the 

Immediate Past President of NOVA. NOVA is the professional organization for registered nurses employed by the Department of 

Veteran Affairs. 

NOVA respects and appreciates what our labor organizations, 

such as AFGE and the National Association of Government Employees (NAGE), do for VA nurses. NOVA clearly deals with VA on 

RN professional matters, not working conditions, for which VHA 

RNs have the union representative. Because this Committee has 

invited NOVA to share its views on this bill however, I am here 

to offer the following observations. 

Nursing and other medical center workforce members are dependent on timely and efficient recruiting. Human resource departments across VHA are not able to function optimally due to systems that have not kept pace with our private-sector recruitment 

abilities. Although there are numerous barriers to timely and efficient recruiting, the following are the top three. 

Although certain pay flexibilities do exist, such as recruitment 

bonuses, retention allowances and the special rate authority, additional pay flexibilities are needed in order for VA to be able to successfully compete for the best candidates in the marketplace. The 

current general schedule and locality pay system, which works 

hand in hand with the classification system, is antiquated and cannot respond quickly enough and has a number of major barriers. 

For example, retention allowances are not considered base pay 

for benefits such as retirement and life insurance. And candidates 

have declined positions based on this limitation. VA’s special pay 

rates—there are restrictions on how far the table can be expanded, 

and the approval process for special rates is too slow to address the 

current market conditions. Above-the-minimum rates allow a manager to appoint an applicant above the minimum step, but there is 

no mechanism, for example, to increase the pay of existing staff to 

maintain pay parity. 

The application process, how to apply, is very cumbersome and 

confusing to those in the private sector who are used to a much 

faster and simpler process. Staffing specialists must help many of 

the would-be applicants to navigate through the maze of the Federal application process. 

A consistent theme across the country is that applicants are looking for money for professional development, not just in clinical occupations but in administrative as well. Tuition reimbursement is 

limited to a few select occupations at this time, such as nurses, 

that still require expansion. 

Some suggested policy changes recommended are as follows: 

More pay flexibility should be provided. Pay reform similar to the 

physician pay reform, where there is a market pay component, 

would provide the needed flexibility for VA facilities at the local 

level. 


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Classification standards are in need of review and revision. Many 

of them are too old and no longer reflective of the types of duties 

and responsibilities that are typically performed. Given that these 

are used to determine the pay, they can often serve as a barrier 

to appropriate and effective pay setting. 

Given the sizable number of employees at or near retirement age, 

succession planning is becoming increasingly important, especially 

for those critical positions. 

One other critical area of concern relates to the impact on patient 

care if 38 U.S.C. 7422 exclusions were to be repealed. Some of the 

issues that I foresee would have a negative impact on the care of 

our veterans include the following: RN reassignment decisions 

made on the basis of clinical competence, performance appraisals, 

and proficiency reports; fitness for duty issues as determined by a 

professional standard board; clinical competence issues as determined by a professional standard board; and disciplinary and major 

adverse actions based on patient care or clinical competence issues. 

Determination of clinical competence is best reserved for those responsible for ensuring that quality care is delivered. 

VA has been a leader in healthcare and has earned an excellent 

reputation as one of the best healthcare providers in the country. 

In order to continue this reputation, VHA’s staff will need to have 

new skills and competencies to treat this new generation of veterans. Nimble and flexible human resource processes are critical to 

VA’s future success. 

Thank you, Mr. Chairman and Members of this Subcommittee, 

for this opportunity to testify here about these important personnel 

issues. And I would be happy to answer any questions. 

[The prepared statement of Ms. McVey appears on p. 52.] 

Mr. MICHAUD. Thank you very much. 

Mr. Atizado. 

STATEMENT OF ADRIAN M. ATIZADO 

Mr. ATIZADO. Mr. Chairman, Members of the Subcommittee, I 

thank you for inviting the Disabled American Veterans to testify on 

human resource challenges within the Department of Veterans Affairs’ Veterans Health Administration. 

As you have been made aware by this panel, as well as the previous panel, the human capital needs of VHA are quite a concern. 

There are a few factors I think that we must talk about before I 

can fully deliver my oral testimony. We have to understand that 

the workforce shortage in the Nation is primarily defined in three 

factors: supply, demand and, obviously, the compensation package. 

Congress has seen fit to address compensation package with regards to the physician pay bill reform as well as VA changing the 

nurses’ compensation package. 

Also, VA has been creating some new initiatives with regards to 

the supply end of the issue. You just heard the concern about not 

enough trainers and preceptors for the healthcare fields. And I 

think that should also be addressed, not only by VA, but by this 

Committee as well. 

I would like to highlight a few factors within VHA that drive the 

human capital needs of VHA. There is a distinct variation in demoVerDate Nov 24 2008 00:45 Mar 10, 2009 Jkt 043054 PO 00000 Frm 00023 Fmt 6633 Sfmt 6633 E:\HR\OC\43054.XXX 43054

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graphics and behavior of the newest generation of VA’s patient population compared to the veterans of previous conflicts. 

On the attrition of its workforce, by 2012, nearly 92,000 VHA 

employees who would be eligible for full civil service retirement. 

Over 46,000 of those are projected to retire. In fact, the health resources and services administration division of the Department of 

Health and Human Services projected a national shortage of nearly 

500,000 nurses by 2010 and over 1 million by 2020. 

Moreover, the unbalanced matriculants and supply of prepared 

healthcare workers, as well as the maldistribution of these workers 

across the U.S., will demand much more of VHA’s human resource 

program. 

Without question, recruitment management and providing direction for VA employees on such issues as hiring compensation, performance management, and organizational development are critical 

to the success of VHA’s mission to provide high-quality care to sick 

and disabled veterans. 

While, as I have mentioned, most recent actions by Congress to 

affect the compensation package of VHA to offer to prospective employees necessitates additional implementation oversight, as mentioned by the previous panel. 

We believe an equally important problem within the realm of recruitment that requires additional attention is the Federal hiring 

process itself. This was touched upon by the previous panel. Hiring 

a new wave of Federal employees to succeed those that leave is 

paramount, given the frequent civil service hiring freezes of the 

past 2 decades and the inadequate funding levels in the unpredictable nature of the discretionary budget process. 

Fortunately, there is a perennial and widely acknowledged complaint by applicants for Federal employment about cumbersome 

Federal hiring procedures and practices which require too much 

time and excessive paperwork. Of those who submit applications, 

many say they never received feedback from agencies of interest. 

The most recent Merit Systems Protection Board’s survey of 

entry-level hires and upper-level hires showed that substantial 

numbers had to wait 5 months or longer before being hired. This 

is much, much too long to expect a high-quality applicant to wait, 

particularly in the healthcare arena, which is extremely competitive. 

As the Subcommittee is aware, VHA’s workforce is covered under 

title 5, title 38 and title 38 hybrid. The greater majority of VHA 

employees fall in title 38 as well as the title 38 hybrid. Personnel 

rules under both were designed to allow greater flexibility and expedite VHA’s hiring and promotion processes. However, the reality 

of hiring and promotion processes are facing extraordinary delays, 

particularly in the boarding process across health disciplines from 

nurses to psychologists, as well as background searches. The Federal hiring process is so daunting that it often reinforces applicants’ worst fears of government as an ineffective, unresponsive 

and incomprehensible bureaucracy. 

In addition, at times there is often poor communication between 

Federal managers and Human Resource professionals on the qualities and skills needed in a candidate. Attrition of experienced VHA 

human resources employees has a direct impact on the quality of 


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recruitment and retention efforts, as well as providing needed assistance to train new and inexperienced staff to successfully hire 

needed VHA employees. Only by insisting that VHA make recruiting talent a top priority, that both agency leaders and managers 

are held responsible for results, and that the individuals involved 

in the hiring process be held more accountable can we ensure that 

VHA recruits the talent needs to meet the challenges ahead. 

Mr. Chairman, this concludes my testimony. I will attempt to answer any questions you may have. 

[The prepared statement of Mr. Atizado appears on p. 54.] 

Mr. MICHAUD. Once again, I would like to thank all three of you 

for your testimony this morning. Just a couple of quick questions. 

You all touched upon retention and talked a lot more about recruitment. What additional programs or tools do you feel that the 

VA can use in trying to retain the employees that they currently 

have? 

I’ll start with Mr. Atizado. 

Mr. ATIZADO. Well, the retention package of VA should first be 

seen in a different light than the recruitment package. As previously mentioned, there are certain things that current employees, 

direct healthcare providers in VHA, look to when they make a decision whether to stay in VA or not, whether it be the education reimbursement package which, by the way, my colleague has mentioned, has expired back in 1998. We believe and we actually recommended that be addressed in a previous testimony last year before the House Veterans’ Affairs Committee. 

In addition, I believe there is a great concern in the Nurse Corps 

with regards to the pay bands. A lot of the well experienced nurses 

in VA are very much at the top tier of the pay band and have nowhere to go. They are, to look across the street at a private 

healthcare system, which will offer more; and obviously there is an 

unequal footing. 

Ms. MCVEY. The pay band cap is an issue for nurses and for 

nurses anesthetists as was testified early. That is one thing. 

Ongoing educational benefits are critical for retention and not 

just for nursing. I think it is very important for the succession 

planning for other deliverers of healthcare, such as human resource 

departments that support the work for nursing, and the workforce. 

To have educational moneys for these people for succession planning would also be very valuable support for the VA Nursing Academy program. This is a program I am not sure you are familiar 

with where the VA has funded last year four pilot programs with 

a VA and an adjoining university, to help bring more nurses into 

the workforce for VA. But it is also an opportunity for VA staff to 

become educators in these universities and give them additional 

opportunities, while still remaining a VA employee, to deliver care 

and also expand our workforce and give that workforce another opportunity to expand their horizon. And that would indeed also help 

retention. 

Mr. COWELL. Mr. Chairman, just to build on what has been said, 

I think VA needs to look at doing a better job with its internal 

scholarship programs. These are great incentives for people to improve their skills, get higher education, and remain loyal employees 

of the VA. 


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We mentioned earlier the EDRP, the Education Debt Reduction 

Program, the cost, especially of medical education, is soaring. For 

people who want to improve their position, improve their skills and 

seek higher educational opportunities, these types of programs can 

help reduce some of that debt that goes with higher medical education. We think that would be an excellent incentive. 

Locality pay is certainly an issue. It needs to be more fairly distributed and available across the system. 

We think flexible schedules are important. It was testified about 

earlier. And in addition, you know, bonuses are not just a recruitment tool, but they are also a retention tool; and we think that pot 

of money needs to be more fairly distributed and available across 

the system. Even, perhaps, a set-aside pool of money in the VA for 

bonuses would be a good idea. Currently, we hear that local facility 

managers have to take that available money out of their existing 

FTEE budget, so when they do that and they have bonus money 

available, then they are not as able to hire the additional staff they 

really need. 

So it is a lot of issues out there and a lot of personnel issues. 

We think a review of section chapter 74 and 76, both the personnel 

and the educational benefits, to take a good look. 

Mr. MICHAUD. Thank you very much. 

Mr. Miller. 

Mr. MILLER. Thank you, Mr. Chairman. 

Mr. Cowell, in your testimony—excuse me, I am sorry. I have 

this about the nurse organization. 

Ms. McVey, in your testimony you raise concerns about including 

matters relating to direct patient care and clinical competence in 

collective bargaining rights. 

Please explain in more detail your concerns. 

Ms. MCVEY. I think—if section 7422 were to be repealed, I think 

that it would cause perhaps some delays because inherent in the 

bargaining process itself is the element of time; and if certain 

issues needed to be negotiated, such as mandatory training on 

traumatic brain injury, as an example, it may delay—not always, 

but in some cases. The implementation of being able to effect that 

training might be one example. 

I also think there is some inconsistent application of section 7422 

across the United States, and this may also be an issue. Perhaps 

it is invoked not appropriately when it should not have been or 

should have been; and I think that is some of the concern right 

now. 

Mr. MILLER. Mr. Cowell, you reiterated in your testimony several 

recommendations for improving VA’s recruitment process from the 

National Commission on VA Nursing. 

Can you give me an idea of what you think may be the top one, 

two, or three of those recommendations? 

Mr. COWELL. Yes. 

We had a meeting with Cathy Rick, who is the head of VA nursing, and we talked a lot about the Commission’s recommendations. 

She told us that many aspects of that have been implemented, and 

it is becoming good policy. But she talked about some of the problems that VA nurses, even though they are in—somewhat always 

in need of more compensation; but there is a lack of organizational 


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sharing responsibility that they feel would be a great incentive to 

make them feel more important and more a part of the healthcare 

team. 

That was something that really came through in our discussion 

with nurses across the system, that they just think they could 

share a greater responsibility in unit planning and unit organization and have a greater responsibility in the administration of 

those areas. 

Mr. MILLER. What effect do you think specialty pay rates for certain nursing professions would have on the recruitment and retention of nurses and physicians that don’t have specialty pay? 

Mr. COWELL. Well, we have—our analysis of the data of the spinal cord injury system, and that is our expertise, there is an agreement and a rule that the nursing service that works in the spinal 

cord injury service, 50 percent of those are supposed to be RNs. 

Our data reveals that very few of the 22 SCI centers in the four 

long-term care facilities meet those requirements. So there is a 

dearth of RNs available to veterans with spinal cord injury. We 

think that is true in the other specialized services as well. 

One of the issues that happens, particularly in the spinal cord 

injury service, is that patients have high acuity needs, and it is 

labor-intensive work. Many of the nurses that work in spinal cord 

injury centers suffer personal injuries. They are on light duty. 

There is a lot of lifting to meet the needs of these veterans that 

are in these hospitals and centers. So it works as a disincentive to 

stay on board those services. 

We think specialty pay will help attract nurses to that type of 

labor-intensive work and help to fulfill that RN requirement. 

Mr. MILLER. The VA has established a Travel Nurse Corps. Can 

you talk a little about that? Do you think it is—— 

Ms. MCVEY. Yes. It is a pilot for the VA to have its, really what 

could be considered its own agency nurses, but these are VA employees; and the goal is to have a trained workforce of VA employees that could theoretically go anywhere in the country and serve 

in the VA in times of need. So there is a pilot project which is 

under way. 

I am not as familiar with it as perhaps Cathy Rick would be at 

this time, but I am aware of it and everyone is very pleased and 

seems to think it is a very good thing. 

Mr. MICHAUD. Mr. Hare. 

Mr. HARE. Thank you, Mr. Chairman. I just have one question 

for the panel. Maybe you could just each take a shot at this. 

Does the VHA coordinate in any capacity with Veterans Service 

Organizations (VSOs) as a resource or recruitment tool, to find veterans who could be hired here? And if not, how do you think that 

could be useful, if they are, you know, A, to what degree and how 

effective have you found that to be? 

Mr. COWELL. I would just say, in my experience, there hasn’t 

been a great deal of collaboration between human resources people 

across the country and the VSOs that PVA has. 

As you know, PVA has started an employment program. It is in 

Minneapolis and in Richmond, Virginia, and it seems like the emphasis is on our end to try to discover what local physicians might 


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feel available and how we can place a veteran in that kind of a position. 

But we haven’t had much contact from the VA toward us. 

Mr. HARE. Would that be helpful to you? Do you think that is 

something that—— 

Mr. COWELL. I think anything that can help get certainly our 

members employed and other veterans is a good idea. And I don’t 

think it would be a real tough step to implement. I think it is a 

matter of communication. 

Ms. MCVEY. I also think it is a very excellent idea. 

We have collaborated with the PVA on local open houses at our 

facility in Boston, and it has worked very well. And as you said, 

any extension on collaboration and the ability to bring in more staff 

into the VA workforce is an excellent idea. 

Mr. ATIZADO. I agree, Mr. Hare. We, DAV, does not have a very 

established relationship with VA’s human resources. It is not one 

of our fortes as more—as it would be for PVA, because it does affect 

directly on their membership, although we do work very closely 

with the ancillary organizations like NOVA and APA and those organizations to try and highlight VHA as a place to work. 

I do believe we would more than welcome in any kind of collaboration we can make with VHA to increase their exposure on that 

end. 

Mr. HARE. I am not sure how we would go about doing that, but 

it would seem to me that if the VHA would coordinate with the 

VSOs, you probably could give them a number of people, or at least 

it would be a resource for them. 

So that, given the need—I want to get the numbers again. The 

shortage of nurses that we are going to see is what? I am sorry; 

I forget who testified about that, but somebody mentioned the 

shortages now or what we are looking at down the road. 

What were those numbers again? 

Mr. ATIZADO. Half a million by 2010. 

Mr. HARE. Half a million. 

Mr. ATIZADO. One million through 2020. This is through Health 

Resources and Services Administration Division of the U.S. Department of Health and Human Services. 

Mr. HARE. We are going to have to get rolling, it would seem to 

me, because that is a huge, huge hole that we are going to have 

to try to fill. 

So, again, I think anything that would work, Mr. Chairman, getting the VHA to talk to the VSOs, would be great, because again 

you are great resources. You have the people, you know them; and 

when you are looking at that kind of shortages down the road, that 

just seems to me to be a natural thing to do. 

So I thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you. 

Mr. Snyder. 

Mr. SNYDER. Thank you, Mr. Chairman. I am sorry I was late 

getting here. 

Ms. McVey, before I started in this, I made my living as a family 

doctor, and I generally found if I did what the nurses say, I would 

stay out of trouble. So I am going to ask my question to you. 


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I met with Mr. Wommack yesterday and did not hear his testimony today, but it seems like, as far as the veterans healthcare 

system—in order to get healthcare professionals on board it seems 

like there are two basic things. Number one, you can flood the 

input with such great numbers that sooner or later enough will 

float through and fill the positions; or you can deal with the input 

that is coming in in such a way that you can increase the percentage of those you end up hiring to fill your positions. 

And my question is, have you—have you done—do you do any 

kind of formal testing, your organization, where you either sample 

people, folks who are making application to the VA system? Or do 

you ever go online yourself or make the phone calls yourself just 

to see what the process is like? 

Do you have any formal way that you judge how people are treated when they actually are interested in working for the VA 

healthcare system? 

Ms. MCVEY. That is a excellent point. 

I chair our local succession planning Committee and we have not 

done that although we have discussed that. What we have done is, 

we have done some research; and we found that many VA employees, and nurses in particular, are vulnerable to leaving the system 

between the third and seventh year of employment. 

So what we did through our succession planning Committee was 

go out and survey a random group of these employee nurses, and 

other employees as well, that are thought to be at the point at 

which they may consider leaving VA employment, and tabulated 

the results to see why they stayed, with the thought being that if 

we could tap into those things and incentives to make them stay, 

we could have a better retention rate for all of our VA employees 

in the Boston VA Healthcare System. 

I am happy to say, for nursing RNs in particular, we have now 

a 5 percent turnover rate, which is extraordinarily low. Nine years 

ago it was 18 percent, so I think things are going well in that particular group. 

But we are also concerned about turnover, though we haven’t 

had as much in the RN group; but that is not necessarily true 

across the country. There have been no other departments that 

support the work of nursing; there are challenges, and many of 

them—some of which I stated in my testimony—had to do with recognition, the ability for a career ladder for non-nursing personnel, 

the moneys for education, et cetera. So we have been trying to 

tackle those on a local level, and it has been very interesting. 

But I also like the thought of serving a group that has not yet 

come. We do hear informal feedback from our staff who are friends 

of the staff that have applied for positions, and that feedback is, 

they are very concerned about the very long and excessive timeline 

between when they apply for employment and when we are actually able to bring them in. 

And so they do tend to get discouraged, and that is a concern of 

ours. 

Mr. SNYDER. You did bring up—in my simplistic analysis, the 

third component is, if you can cut down on people quitting, then 

you don’t have so many openings that you need to fill. 


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But the issue of—I have actually done this before in different 

things, where I get an internist, say, Here, call this help line, and 

here is the story I want you to read; see what kind of information. 

I would think that a group like yours could get some nurses and 

kind of test how quickly—once you make an inquiry, how quickly 

do you get responded to. 

As you know, the market is such out there, if somebody applies 

for a job or goes online and makes an initial inquiry, the nurses 

market being what it is, if it is a week or 2 or 3 days before they 

hear back from somebody, they will have other job offers if they are 

very aggressive and have a reasonable-to-average work record. 

That might be helpful information both for you and this Committee if you, with your—you probably have the ability to do something that we don’t have, which is, you can do those kinds of test 

cases to different VAs around the country, and because I think that 

would be helpful. 

I know Mr. Wommack is concerned about streamlining. And the 

streamlining basically is, we need to have a description of what the 

current process is. And I don’t know that we have that yet, but—— 

Thank you for you all’s participation today. 

Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you. 

Once again, I would like to thank our panelists for coming out 

and for your testimony as well. Thank you very much. 

Our last panel is Joleen Clark, who is the Chief Officer of Workforce Management and Consulting with the VHA. 

I want to thank you, Joleen, for your willingness to come here 

this morning as well. We probably will be having votes shortly, so 

if you can, summarize your written testimony and the complete 

copy will be submitted for the record. 

STATEMENT OF JOLEEN CLARK, CHIEF OFFICER, WORKFORCE MANAGEMENT AND CONSULTING, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS 

Ms. CLARK. Thank you, Mr. Chairman and Members of the Subcommittee. Thank you for the invitation to appear before you to 

discuss human resource challenges within the Department of Veterans Affairs, Veterans Health Administration. As the Nation’s 

largest integrated healthcare delivery system, VHA’s workforce 

challenges mirror those of the healthcare industry as a whole. 

VHA performs extensive national workforce planning and annually publishes a workforce succession strategic plan. VHA’s strategic plan addresses current and emerging initiatives, the areas of 

including, but not limited to, recruitment and retention, mental 

healthcare, polytrauma traumatic brain injury and rural health to 

address workforce efforts. 

VHA’s workforce plan is one of the most comprehensive in government and has been recognized by OPM as a Federal best practice. It is important that the supply of appropriately prepared 

healthcare workers meets the need of a growing and diverse population. Enrollment in nursing schools needs to grow to meet the 

projected future demand for healthcare providers. 


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In an effort to initiate proactive strategies to aid in the shortage 

of clinical faculty, VA launched the VA Nursing Academy to address the nationwide shortage of nurses. The VA Travel Nurse 

Corps is an exciting new program that establishes a pool of registered nurses in VA who can be available for temporary short-term 

assignments at VA medical centers throughout the country. This 

program is being piloted at two sites, Phoenix and San Diego. 

Student programs such as the VA Learning Opportunities Residency Program, the Student Career Experience Program and the 

Hispanic Association of Colleges and Universities Internship Program have helped VA meet the workforce succession needs. The 

Graduate Health Administration Training Program provides practical work experience to students and recent graduates of 

healthcare administration Master’s programs. 

VA recognizes that rural communities face additional healthcare 

workforce challenges. VA is working to develop an effective rural 

workforce strategy to recruit locally for a broad range of healthcare 

professionals. 

Experiential training opportunities for young medical students 

are important investments for creating a veteran and rural friendly 

physician workforce. Last year VHA’s Human Resource Committee 

chartered a work group to streamline the recruitment process for 

title 5 and for title 38 physicians within VHA. The work group initially analyzed the recruitment process and identified barriers and 

lengthy processes for registered nurses. The work group recommendations were then piloted and are now in the process of 

being implemented nationally. 

One retention strategy that has proven very successful for VHA 

was approved in Public Law 108–445. The public law improves 

VA’s ability to recruit and retain the best qualified workforce capable of providing high-quality care for eligible veterans. The VHA 

Healthcare Recruitment and Retention Office administers national 

programs to promote employment branding within VHA as a 

healthcare employer of choice. 

Both a recruitment and retention tool, the Employee Incentive 

Scholarship Program pays up to $35,900 for academic healthcarerelated degree programs. Between 1999 and May of 2008, over 

7,500 VA employees have received scholarship awards for academic 

education programs related to title 38 and hybrid title 38 occupations. And more than 4,200 employees have graduated from those 

programs. 

The Education Debt Reduction Program provides tax-free reimbursement of education loans debt to recently hired employees, 

both title 5 and hybrid title 38. EDRP is similar to the student loan 

repayment programs for title 5 employees. VHA routinely uses hiring and pay incentives established under title 5 and title 38. Recruitment and retention incentives are used to reduce turnover 

rates and help fill vacancies. 

In 2000, VA began to use an electronic database to capture survey information from employees entering and exiting VA’s service. 

The entrance survey is an excellent tool for comparing and contrasting reasons new employees have come to work for VHA. 

The Under Secretary for Health has made a personal commitment to succession planning and ensuring VHA has a comprehenVerDate Nov 24 2008 00:45 Mar 10, 2009 Jkt 043054 PO 00000 Frm 00031 Fmt 6633 Sfmt 6633 E:\HR\OC\43054.XXX 43054

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sive recruitment, retention, development and succession strategy. 

This is a continuous process which requires ongoing modifications 

and enhancements to our current programs. 

I would like to thank the Subcommittee for your interest and 

support in implementing legislation that allows us to compete in 

the healthcare market. Thank you. 

Mr. MICHAUD. Thank you very much for that enlightening testimony. 

[The prepared statement of Ms. Clark appears on p. 56.] 

Mr. MICHAUD. Mr. Miller. 

Mr. MILLER. Thank you, Mr. Chairman. I have several questions 

that I am going to submit for the record in view of time. 

[No questions were submitted.] 

Mr. MILLER. But how does VA use the tools that it currently has 

at its disposal to help recruit staff that have been hard to recruit 

and retain? 

Ms. CLARK. The Education Debt Reduction Program is one of the 

most successful tools that we do have, and that, as mentioned, has 

been used to recruit healthcare professionals in both title 38 and 

hybrid title 38. So far, over 6,500 participants have received funding with an average award of $29,000. Right now, the cap is at just 

over $50,000 for those awards. And, yes, some students are coming 

out of school with higher debt than that, but it has been very effective in recruiting healthcare professionals. 

We also use recruitment incentives extensively in areas where 

they have felt that they are needed to recruit staff. We draw people 

in with our scholarship program, our Employee Incentive Scholarship Program that we have for both title 38 and hybrid title 38 occupations. 

Mr. MILLER. Talk to me about that just a little bit, the scholarship program. 

Ms. CLARK. The scholarship program is available to employees 

after they have had 1 year of employment. We have had 7,500 that 

have entered into the program. It is open to all occupations that 

fall under title 38 and hybrid title 38. It is up to 3 years of schooling, up to 35—it is over $35,000 that it pays out for scholarships 

in those occupations. 

Mr. MILLER. Thank you. 

Ms. CLARK. You are welcome. 

Mr. MICHAUD. Mr. Hare 

Mr. HARE. Thank you, Mr. Chairman. 

The RAND Corporation recently released reports stating that 

about 300,000 soldiers report symptoms of PTSD or major depression, and only half of those are seeking treatment. This conflict in 

particular has put a new focus on the importance of treating mental health problems. 

Should the VA be reexamining if psychologists should continue 

to be in the hybrid title 38 program, do you think? 

Ms. CLARK. The difference between hybrid title 38 and title 38 

doesn’t reside in how the person is boarded. It resides in—the two 

things that are covered by hybrid title 38 are pay and appointments, and they are covered under title 5 for everything else. 

The setting of the pay and the grade that they go to is the same 

under title 38 and hybrid title 38, so that would not make a difVerDate Nov 24 2008 00:45 Mar 10, 2009 Jkt 043054 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 E:\HR\OC\43054.XXX 43054

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ference; and I don’t know how it would make a difference in how 

care is provided. 

Mr. HARE. Do you think that VA should diversify its loan repayment or scholarship programs? For certain medical professions, a 

physician can accrue about $150,000 in debt in medical school 

costs, yet they are only eligible for about $46 to $50,000 from the 

VA. 

Ms. CLARK. Yes. We have found that many of the doctorate programs, along with the physicians, are coming out of school with 

debt in excess of $100,000. And although the Education Debt Reduction Program certainly helps with $50,000, you know, many of 

them would benefit from larger loan repayment. 

Mr. HARE. One last question I had asked the last panel because 

it seemed to make a little sense about the working with—the VA 

working with different VSOs to try to find some folks who might 

be interested in going into the field. 

I was, candidly, very alarmed when I asked the question about, 

you know, the half-million or 500,000 nurse shortage and then up 

to 1 million; and it just seemed to me that anything and everything 

that the VA can do, or that we can do, or whoever can go do to 

try to fill that hole, because we are going to see more veterans coming back. Obviously, the need is going to be greater. 

So I wonder if you had a thought or two on that. 

Ms. CLARK. That was a great suggestion. There are new positions 

that have been added to the organization called Veterans Employment Coordinators, that are placed strategically through the country; and that will be a great opportunity for them to contact the 

local VSOs and try to coordinate with them and get information out 

on any of the recruitment activities that we have going on in the 

local areas. 

Mr. HARE. I appreciate that because, again, I think it would be— 

I think we have to have all hands on deck to try to help the program out here. 

Mr. MICHAUD. Ms. Clark, you had mentioned the VA’s working 

to integrate rural areas into the residency rotation. 

How far along are you with that program and who are you working with to accomplish that. 

Ms. CLARK. The Office of Academic Affiliations is working closely 

with the medical schools in the local areas to address that. I don’t 

know how far they are along in that. I can get that information 

back to you. 

[The VA response is included in the response to Question #4(b) 

in the post-hearing questions for the record, which appears on 

p. 63.] 

Ms. CLARK. But that is something that we have been really concerned about and thought, if we get those students, trainees and 

residents into those rural areas and have them do their training 

programs and residencies there, the likelihood that they would return and stay in that area for employment is much higher. 

So that was the thought behind doing that and increasing the 

employment in those areas in our critical occupations. 

Mr. MICHAUD. Do you have programs doing that and how many 

States are involved in that? 


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Ms. CLARK. There is not a pilot program yet. I am sure we will 

have pilot programs that we will have doing the rural health, the 

residencies in the rural areas. 

Mr. MICHAUD. You heard the other two previous panels talk 

about the hiring process and dealing with hybrid title 38, which is 

onerous and potentially actually could cause VA to lose good employees. 

What is the number one reason that candidates are turned down 

for employment within the VA system? 

Ms. CLARK. We are aware of the problem, and as I mentioned we 

have done a redesign look and see at the whole process and our 

end process of implementing numerous changes. 

It is not just one thing. It is our paperwork; we have way too 

much paperwork. It is some of our internal policies that we are 

finding are really obsolete with some of the things we have to do 

with the credentialing process. Our credentialing process is very 

onerous, but very necessary to make sure that our staff have the 

appropriate credentials for patient care. 

But we are looking at a process that we can do simultaneously, 

so it doesn’t take as long, eliminating steps that don’t need to be 

taken. 

The background investigations that we have to do take some 

time, but also looking at combining processes and trying to eliminate unnecessary steps is helping tremendously. I think, just looking internally, we can probably, without changing regulation or 

statute, improve the process tremendously; and we are working toward that. 

In the pilot they showed that it can be done in 30 days to bring 

somebody on and going through all these credentialing processes 

and background investigations, et cetera; and we are rolling that 

out throughout the country, having targeted Human Resource cluster meetings so that word can get out, they can understand what 

we are looking for and assist them in getting there. 

Mr. MICHAUD. What do you believe VHA’s number one challenge 

is in filling the shortage in the positions that you have? Is it more 

prominent in any one region of the country than another? 

Ms. CLARK. I can’t say that it is more prominent in any region, 

but there are specific areas, certain rural areas, certain demographic areas that might not have schools in the area that have 

greater challenges in certain occupations. Through our succession 

and workforce planning, we look at those things and try to build 

recruitment and marketing strategies to address those areas where 

we are having the recruitment problems. 

We have—throughout the Nation, when the workforce planners 

do their plans, we come up with a list of what we consider our critical occupations in VA; and we target those occupations for additional recruitment strategies to look and ensure that we have the 

appropriate workforce. 

Mr. MICHAUD. What are the top three critical occupations it 

needs? 

Ms. CLARK. Medical doctor positions and pharmacists, are always 

our top three. 

Mr. MICHAUD. When you look at pharmacists, you are looking at 

working in the academic world as well? I know pharmacy schools 


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are pretty expensive to have. Are you looking in that area as well— 

in the rural areas? 

Ms. CLARK. We haven’t looked at the rural areas yet. 

What they have just recently started, last year in 2007, is the 

VALOR program, VA Learning Opportunity Residency, for pharmacists; and they have increased the number this year. And some 

of those are in—I don’t know if I would call them rural, but in lesspopulated areas, and they are continuing to expand. 

The pharmacy leadership has been really excited about how the 

program has taken off and is looking to expand it; and this is with 

the pharmacy doctorate programs. And it is working really well, 

and we are hoping that they stay in the VA after they finish their 

residency program. 

So we think this will be a great recruitment tool. 

Mr. MICHAUD. Is there anything that we can do to help deal with 

the shortage that you foresee? 

Ms. CLARK. Thank you for the offer. 

Right now, what we are trying to do is work through some of the 

issues internally to see how we can improve the hiring and on 

boarding process; and if there is something you can do to help, we 

certainly will let you know. Thank you. 

Mr. MICHAUD. And how long is that internal review going to 

take? As you heard earlier, there is a severe problem out there, and 

the longer we wait, the less likely we are able to get these good, 

qualified healthcare providers in the VA system. 

Ms. CLARK. We certainly understand that. 

We have already implemented it in several of our networks, and 

it is going to be a performance measure for all of the network and 

medical center directors for 2009 to have it down to the 30-day hiring process. We anticipate that it will be happening by the time 

2009 gets here; though, you know, there are a lot of challenges. A 

lot of people are at really long timeframes, so will they get down 

to the 30. But we are hoping at least they can cut their timeframes 

in half. 

Mr. MICHAUD. What Veterans Integrated Services Network 

(VISN)? 

Ms. CLARK. VISN 4 is the one that piloted the recruitment redesign, but several other networks have already implemented it as 

well. 

Mr. MICHAUD. What are you doing to work with the Office of 

Rural Health, as well, to look at some of these needs, realizing that 

the office is, in my opinion, adequately understaffed. 

Ms. CLARK. We are working hand in hand with them in the recruitment issues to try to come up with a recruitment plan so that 

we can—they can identify some of the things and then we can work 

with them on how, trying to meet those challenges. And I think 

that is how Academic Affiliations came up with the plan for working with the schools to try to get some of those residents into those 

under-served areas. 

Mr. MICHAUD. My other question involves rural areas where 

there is a healthcare shortage, not only within the VA system. If 

you look at the Capital Asset Realignment for Enhanced Services 

(CARES) Process, 2004, when their report came out, they recVerDate Nov 24 2008 00:45 Mar 10, 2009 Jkt 043054 PO 00000 Frm 00035 Fmt 6633 Sfmt 6633 E:\HR\OC\43054.XXX 43054

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ommended a lot of access points, particularly in rural areas, and 

they haven’t moved as aggressively as a lot of us would like to see. 

My question is, what are you, the VA, doing to work with local 

healthcare providers in States to deal with the healthcare shortage, 

and are there ways that you can partner with the healthcare providers currently out there, keeping in mind the CARES Process, 

might recommend to provide access points in rural areas? 

Ms. CLARK. I am not sure what they are doing. I know that some 

local facilities do contract with those in areas where they have the 

clinics, et cetera, but I can take that question back for the record. 

[The VA response is included in the response to Questions #4(a) 

in the post-hearing questions for the record, which appears on 

p. 62.] 

Mr. MICHAUD. Do you have any additional questions? 

Once again there will probably be additional questions, later on, 

in writing. 

Mr. MICHAUD. We really appreciate your willingness to come 

today. It has been very helpful. This is an extremely important 

issue, one that we are going to have to deal with soon if we are 

going to make sure that our veterans have adequate healthcare 

here. Once again, thank you very much for your testimony today. 

We look forward to working with you as we move forward in this 

Congress. 

So if there are no other questions, this hearing is adjourned. 

Thank you. 

[Whereupon, at 11:40 a.m., the Subcommittee was adjourned.] 


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(33) 

A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud, Chairman, 

Subcommittee on Health 

Thank you everyone for coming today. 

The Veterans Health Administration’s mission is to provide patient centered 

healthcare that is comparable with or better than care available in the non-VA sector. To do this, VHA must have a viable healthcare workforce that is competent, 

well trained and happy. 

Over the past 5 years, VA has built a reputation of delivering healthcare efficiently and effectively. VA has been touted as the ‘‘best care anywhere’’ and the Department has been recognized on numerous occasions for healthcare quality and patient satisfaction. 

However, in order to carry that banner forward, careful planning and efficient 

processes must be put into the system to ensure continued success. 

We know that VA’s workforce is aging, with an average age of 48.6 years. We 

know that at the end of 2012 a significant percentage of the employees will be eligible to retire. 

This Subcommittee has held many hearings that examined the appropriateness 

and quality of care and treatment that veterans receive within the healthcare system. 

This hearing today will focus on the human resource challenges that VHA must 

address in order to ensure there will not be a gap in the expertise and quality of 

care provided to veterans. 

The Committee realizes that this is a complex issue. But we also recognize that 

it is an important one that deserves serious thought and consideration. 

Thank you again for coming today. 

f 

Prepared Statement of Hon. Jeff Miller, Ranking Republican Member, 

Subcommittee on Health 

Thank you, Mr. Chairman. 

I appreciate your holding this hearing today to examine the many challenges VA 

faces in hiring and keeping healthcare workers. 

Healthcare workers are the frontline of VA healthcare. Every day they care for 

our servicemembers who have honorably served our country. And the high quality 

of healthcare available to our veterans is dependent on the ability of VA to recruit 

and retain qualified healthcare personnel. 

One of the most pressing problems we face as a Nation is the marked shortage 

of virtually all healthcare workers. This includes, among others, nurses, physicians, 

physician assistants, psychologists, pharmacists, and physical and occupational 

therapists. 

Competition for these and other healthcare personnel is intense and VA must aggressively vie with the private sector to bring the very best staff into the VA system. 

To do that, VA must effectively use innovative recruitment tools and offer a good 

work environment with educational opportunities. 

The VA healthcare system has been recognized for the significant benefit of its 

use of electronic medical records and focus on preventative care. And, to make sure 

that our veterans continue to receive the best care, it is critical that it is also seen 

as the workplace of choice. 

I look forward to hearing from our witnesses today to learn about issues they see 

and ideas they have for improving VA’s ability to recruit and retain a first-class 

healthcare workforce. 

Thank you, Mr. Chairman, and I yield back the balance of my time. 

f 


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Prepared Statement of J. David Cox, RN, National Secretary-Treasurer, 

American Federation of Government Employees, AFL-CIO 

The American Federation of Government Employees (AFGE) appreciates the opportunity to present its views on human resources challenges within the Veterans 

Health Administration (VHA). AFGE represents nearly 160,000 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 personnel rules known as 

‘‘pure Title 38’’ providers (e.g. registered nurses (RN), physicians and physician assistants (PA)) or ‘‘hybrid Title 38’’ (e.g. licensed practical nurses (LPN), pharmacists, 

psychologists and social workers). The Title 38 boarding process for appointment 

and promotion of these two groups of VHA professionals was designed to be more 

flexible and expeditious than Title 5, but as will be discussed, the process faces extreme delays and backlogs. A small number of VHA direct patient care positions remain under Title 5, e.g., Nursing Assistants and Medical Technicians. 

AFGE’s testimony focuses primarily on two significant human resource challenges 

facing VHA today: 

• Loss of grievance rights for ‘‘pure Title 38’’ employees; 

• Extreme delays in the ‘‘hybrid Title 38’’ boarding process; 

In my nearly 25 years as a registered nurse and union official at the Salisbury, 

North Carolina VA Medical Center, I have seen the impact of many Veterans 

Health Administration (VHA) personnel policies on recruitment and retention of 

healthcare professionals. In the eighties, I saw first hand how regular collaboration 

between frontline providers and management helped transform the VA into a worldclass healthcare system, becoming a model in patient safety, healthcare information 

technology, and best practices. 

Sadly, what I have seen over the past 7 years is a sea change in VA’s personnel 

practices that now hurt, rather than help, recruitment and retention, and exclude 

frontline providers from medical affairs. The current culture of exclusion is very demoralizing to these dedicated providers who are extremely committed to the mission 

of the VA and work so hard to care for our veterans. For example, according to a 

January 2008 VA national RN satisfaction survey, for the past 2 years, ‘‘Participation in Hospital Affairs’’ was one of two areas where RNs at VA medical facilities 

were the least satisfied. 

Loss of grievance rights for ‘‘pure Title 38’’ employees 

The most harmful, far-reaching VHA personnel policy in place today is the severe 

erosion of collective bargaining rights (hereinafter ‘‘grievance rights’’) of RNs, physicians, PAs and other pure Title 38 providers (‘‘providers’’.) These rights include the 

right to challenge management personnel actions through grievances, arbitrations, 

labor-management negotiations, unfair labor practices (ULPs) and litigation before 

the Federal Labor Relations Authority (FLRA) and courts. 

VHA denies these rights by asserting an arbitrary and unsupported interpretation 

of 38 USC § 77422 (‘‘7422’’), the law that provides collective bargaining rights to 

these providers. VA’s 7422 policy blocks virtually every provider grievance on the 

basis of three narrow exceptions in the law: professional conduct and competence 

(defined as direct patient care or clinical competence); peer review; and compensation. 

VHA’s 7422 policy has undermined Congress’ attempts to improve VHA recruitment and retention through rights to better pay and schedules. The effect, to quote 

the old adage, is ‘‘rights without remedies’’ which ‘‘are no rights at all.’’ 

AFGE greatly appreciates the support of Chairman Michaud and Subcommittee 

Members Berkley, Brown and Doyle for H.R. 4089, legislation introduced by Committee Chairman Filner to amend section 7422 and restore these critical rights. This 

bill is an essential enforcement tool for all past and future legislation that addresses 

VHA recruitment and retention of pure Title 38 providers, as well as Federal statutes that provide rights to information and prohibit employment discrimination. 

VHA’s 7422 policy directly contradicts Congressional intent as to the scope of 

these three exceptions. Specifically: 

• Congress viewed Title 38 and Title 5 employees as having the same collective 

bargaining rights when it enacted the Civil Service Reform Act (CSRA) in 1978. 


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• Congress enacted section 7422 in direct response to a 1988 Federal appeals 

court decision involving annual nurse ‘‘comparability pay’’ increases. The Court 

held that the VA could not be compelled by the CSRA to engage in collective 

bargaining over conditions of employment for Title 38 providers. Colorado 

Nurses Ass’n v. FLRA, 851 F.2d 1486 (D.C. Cir. 1988). 

• The plain language of the 1991 law narrows the scope of the exceptions by 

specifying that the matter must relate to ‘‘direct patient care’’ or clinical competence.’’ 

• The 1990 House Committee report on the underlying bill defined the ‘‘direct patient care’’ exception as ‘‘medical procedures physicians follow in treating patients.’’ This report also cited guidelines for RNs wishing to trade vacation days 

as falling outside the exception. (H. Rep. No. 101–466 on H.R. 4557, 101st 

Cong., 2d Sess., 29 (1990)). 

VHA’s 7422 policy also contradicts its own 1996 agreement with labor to clarify 

the scope of the law and resolve remaining disputes in a less adversarial manner. 

Sadly, the VA unilaterally abandoned this useful, inclusive agreement in 2003. More 

specifically, in that agreement: 

• The VA committed to a new process for resolving 7422 disputes that departed from the ‘‘adversarial, litigious, dilatory . . . nature of past labor-management relations.’’ 

• The VA acknowledged that providers provide valuable input into medical affairs: ‘‘We recognize that the employees have a deep stake in the quality 

and efficiency of the work performed by the agency.’’; ‘‘The purpose of labormanagement partnership is to get the frontline employees directly involved in 

identifying problems and crafting solutions to better serve the agency’s customers and mission.’’ 

• The VA recognized the narrow scope of the direct patient care exception, i.e., it does not extend to ‘‘many matters affecting the working conditions 

of Title 38 employees [that] affect patient care only indirectly’’ (emphasis provided). 

• The VA agreed that scheduling matters may be grievable: ‘‘For example, 

scheduling shifts substantially in advance so that employees can plan family 

and civic activities may make it more expensive to meet patient care standards 

under certain circumstances. That does not relieve management of either the 

responsibility to assure proper patient care or to bargain over employee working 

conditions.’’ 

• The VA agreed that pay matters other than setting pay scales are 

grievable: ‘‘Under Title 38, pay scales are set by the agency, outside of collective bargaining and arbitration. Left within the scope of bargaining and arbitrations over such matters as: procedures for collecting and analyzing data used 

in determining scales, alleged failures to pay in accordance with the applicable 

scale, rules for earning overtime and for earning and using compensatory time, 

and alternative work schedules.’’ 

The 7422 appeals process: 

Section 7422 gives the Undersecretary of Health (USH) the sole authority to determine what matters are grievable. USH decisions are posted on the VA Web site 

(http://www1.va.gov/lmr/page.cfm?pg=28). The VA does not keep AFGE apprised of 

unpublished decisions or pending cases. 

AFGE is very concerned by the lack of meaningful, balanced review by the USH 

and by failure of local facilities to comply with the USH review process. 

A review of posted decisions and member reports received by AFGE reveals how 

VA’s 7422 policies directly undermine recruitment and retention legislation passed 

over the past decade and deprive providers of a fair appeals process. 

For example: 

• No right to grieve over denial of request to review nurse locality pay survey data 

• Background: Congress enacted legislation in 2000 to authorize directors to 

conduct third party surveys to set competitive nurse pay (P.L. 106–419). 

• USH Ruling: ‘‘Compensation’’ exception blocks employees’ access to third 

party survey data. (Decision dated 1/06/05) 

• No right to grieve over VA nurse mandatory overtime policy 

• Background: Congress enacted legislation in 2004 requiring facilities to establish policies limiting mandatory overtime except in cases of ‘‘emergency’’ 

(P.L. 108–445). 


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• USH Ruling: National grievance over definition of ‘‘emergency’’ for requiring 

overtime is barred by the ‘‘professional conduct or competence’’ exception. 

(Decision dated 10/22/07). 

• No right to grieve over composition of panels setting physician pay 

• Background: Congress enacted legislation in 2004 to use local panels of physicians to set market pay that would be competitive with local markets (P.L. 

108–445). AFGE contended that management unfairly excluded practicing clinicians and employee representatives from the panels. 

• USH Ruling: Grievance barred by ‘‘compensation’’ exception. (Decision dated 

3/2/07). 

• Other grievances blocked by VA’s 7422 policy (based on member reports of pending disputes or unpublished USH decisions) 

• No right to challenge intimidation of arbitration witnesses: After two VA 

nurses testified for the union at arbitration, management sent them letters 

questioning their conduct and suggesting that they could be subject to discipline. The union filed an unfair labor practice with the FLRA which initiated steps to file charges against management. Management invoked the 

‘‘professional conduct or competence’’ exception to suspend FLRA action pending an USH ruling. 

• No right to challenge performance rating based on use of approved leave: 

Management invoked 7422 when a nurse tried to grieve the lowering of her 

performance rating that was based on her authorized absences using earned 

sick leave and annual leave, and carried out without any written justification. 

• No right to challenge error in pay computation: Management invoked 7422 

when a nurse was incorrectly denied a within-grade pay increase because of 

lost time arising out of a work-related injury covered by workers compensation. 

• No right to challenge low reimbursement for costs of required training: Management invoked 7422 when a nurse tried to grieve the amount of reimbursement she received for attending required training to maintain her Advanced 

Practice RN certification. 

• Exclusion from hospital affairs: Management invoked 7422 to block a local 

union’s efforts to have input into the drafting of medical staff bylaws that impact personnel policies. 

• No right to challenge unfair bonus policies: VA physicians are unable to challenge policies that are not in compliance with the 2004 physician pay law because managers set arbitrarily low bonuses and impose unfair performance 

measures based on factors beyond the physician’s control. 

Recent court decisions confirm the need for Congressional action on 7422: 

• AFGE Local 446 v. Nicholson, 475 F.3d 341 (D.C. Cir. 2007). The Federal court 

held that the VA operating room nurses could not file a grievance over denial 

of premium pay weekend and evening shifts. 

• AFGE Local 2152 v. Principi, 464 F.3d 1049 (9th Cir. 2006). 

A VA physician was removed from his surgical duties at age 76 and his 

specialty pay was discontinued. The court held that the physician’s grievance alleging unlawful age and gender discrimination was barred by the 

‘‘professional conduct or competence’’ exception in 7422. 

The court rejected the union’s contention that management’s 7422 assertion was a mere pretext for unlawful discrimination. Similarly, in a posted 

USH decision dated 6/1/07, a nurse alleging that management’s denial of 

specialized skills pay was racially motivated was not allowed to pursue a 

grievance. 

Amending 7422 will not hurt patient care. Those defending VA’s current 7422 

policy are likely to suggest that labor will try to disrupt patient care if 7422 is 

amended. In fact, Title 5 makes the three exceptions in 7422 redundant and unnecessary. Federal sector unions are only authorized to negotiate on ‘‘conditions of employment’’ as that term is defined in 5 USC 7103(a)(14). In contrast, 5 USC 

7106(a)(1) makes it a management right (i.e., not to be modified at the bargaining 

table) for an agency to determine its ‘‘mission.’’ 

Furthermore, a review of published cases that have come before the USH did not 

reveal even one attempt to interfere with medical procedures or other direct patient 

care matters. 


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Finally, if grievance rights can interfere with VHA operations, then why do hybrid 

Title 38 providers hired under Title 5 and working side by side with ‘‘pure’’ Title 

38 providers have rights to grieve over these prohibited matters? For example, psychologists have full grievance rights while psychiatrists do not; licensed practical 

nurses have full grievance rights while RNs do not. 

The current dispute resolution process for 7422 is broken and biased 

against employees. Those defending VA’s current 7422 policy are also likely to 

argue that employees already have a fair process though the USH for resolving 7422 

disputes. Numbers tell a very different story: Of the 25 published USH decisions 

over the past 3 years, the USH ruled in favor of management one hundred percent 

of the time. Opponents are unlikely to mention that many, many more cases never 

get to the USH even though the law clearly states that he has sole authority to 

make these rulings. Across the country, human resource departments with no authority regularly make 7422 determinations and refuse to go through the proper 

USH channels. 

The current 7422 process wastes taxpayer dollars. Finally, the VA’s 7422 

policies result in a great waste of taxpayer dollars that would be much better spent 

on patient care. The Asheville case previously discussed was pending for seven years. HR departments in facilities around the country regularly block or delay the 

section 7422 review process, draining resources and staff time away from the VA’s 

mission of caring for veterans. 

Extreme delays in the hybrid Title 38 boarding process 

Congress’ primary objective in establishing hybrid Title 38 positions (i.e., employees are hired under Title 5 but appointed and promoted at the facility level under 

Title 38) was to expedite the appointment and promotion of more VHA employees 

involved in direct patient care. Unfortunately, the hybrid boarding process has been 

anything but expeditious. Employees involved in medical care and mental health 

treatment, including the large numbers of psychologists and social workers the VA 

is trying to bring on board, are facing extreme delays in appointment and promotion 

A second concern is the impact of this process on veterans’ preference in employment. OIF/OEF veterans experience great difficulty in securing and retaining employment, including reservists and members of the National Guard who return to 

Federal service following active duty. VA employees lose veterans’ preference protections when they are converted from Title 5 to Title 38 status. All veterans, whether 

they are covered by Title 38 or Title 5, should have equal employment opportunities 

in the VA, which strives to be a model employer of veterans. 

We urge the Subcommittee to reject proposals to convert additional Title 5 employees to hybrid status. A substantial increase in the number of covered employees 

would be disastrous. Rather, we recommend the suspension of all hybrid boarding 

pending completion of a pilot project using a streamlined Title 5 hiring process and 

comparative study of the two systems. AFGE would like to work with the Subcommittee to develop this pilot project. A pilot project using an alternative Title 5 

process can also provide valuable lessons for other Federal agencies. 

Other human resources challenges 

Physician Pay Law: 

AFGE urges this Subcommittee to conduct oversight into the many problems surrounding the implementation of the physician and dentist pay provisions in P.L. 

108–445, Department of Veterans Affairs Health Care Personnel Enhancement Act 

of 2004. 

Congress’ primary objective in enacting these provisions was to reduce the use of 

expensive fee basis physicians and dentists and fill vacancies at medical facilities 

has clearly not been achieved. The law required the VA to provide an initial report 

on progress toward this goal to Congress followed by five annual reports. AFGE is 

not aware of a single report having been published to date. Meanwhile, many facilities face severe recruitment problems and the VA continues to spend substantial 

sums on costly contract care, including Project HERO, a pilot project impacting 23 

States. 

Problems are evident both in the law’s market pay and performance pay systems 

for physicians and dentists, specifically: 

• Improper composition of local compensation panels setting market pay for individual providers; 

• Management’s refusal to share market pay survey data; 

• The VA’s unilateral reduction of the maximum performance pay award set by 

Congress; 


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• In many facilities, there have been severe delays in developing performance pay 

criteria; • Most criteria were developed without any input from frontline provider or employee representatives; • Many of the criteria are improper, for example penalizing missed patient appointments, which is clearly beyond the provider’s control. 

AFGE urges the Subcommittee to conduct its own study of the law’s effectiveness, 

including the following criteria including in the law’s reporting requirement: rates 

of pay by facility and specialty; rates of attrition; number of unfilled positions in 

each specialty and length of time positions have been unfilled; and, a yearly comparison of staffing levels, contract expenditures, and average salaries. 

Nurse Alternative Work Schedules: In 2004, Congress authorized facility directors 

to offer nurse alternative work schedules (AWS) in the form of full-time pay for 

three 12-hour work days. This schedule option is widely available in the private sector. AFGE is not aware of a single VA facility that has offered AWS to date. We 

urge the Subcommittee to stop relying on the discretion of facility directors who are 

resistant to implementing AWS, and mandate by law that facilities offer this option 

consistent with their prevalence in the local labor market. 

Equality for Part-Time Nurses: Part-time nurses represent a valuable resource to 

VHA. We recommend that Title 38 be amended to enable part-time nurses to earn 

the same rights and job security as their full-time colleagues. Also, many full-time 

nurses convert to part-time status for family and other personal reasons after they 

acquire permanent status. Changing to a part-time schedule should not result in a 

loss of permanent status. 

Thank you. 

f 

Prepared Statement of Randy Phelps, Ph.D., Deputy Executive Director 

for Professional Practice, American Psychological Association 

Chairman Michaud, Ranking Member Miller, and distinguished Members of the 

Committee, I am Dr. Randy Phelps, Deputy Executive Director for Professional 

Practice of the American Psychological Association (‘‘APA’’), the largest association 

of psychologists, with approximately 90,000 full members and 50,000 graduate student members engaged in the study, research, and practice of psychology. I am a 

licensed clinical psychologist, a former practitioner, clinical researcher and educator, 

and for the past 15 years on the APA executive staff, have served as APA’s liaison 

to professional psychology in the Department of Veterans Affairs (VA). 

APA appreciates the opportunity to testify today about human resource challenges 

within the Veterans Health Administration (VHA) that have a direct impact on the 

recruitment and retention of doctoral psychologists to provide care to this Nation’s 

heroes. I should note at the outset that VHA is the workplace of choice for many 

of our members, with about 2,400 psychologists currently in the system. VA is, in 

fact, the largest single employer of psychologists in the country. APA supports VA’s 

recent and aggressive efforts to recruit new psychologists but has concerns about a 

number of policies and procedures which are negatively affecting both recruitment 

and retention. 

APA’s Contribution to Growing Needs 

Professional psychology as a discipline was ‘‘born’’ as a result of the needs of this 

Nation’s returning World War II heroes, and psychologists are acutely aware of the 

debt we owe to those veterans and to the brave men and women who have followed 

in their footsteps, as well as to the system of care this country has evolved to minister to their healthcare needs. 

And, APA is acutely aware that there are over 200,000 homeless veterans on 

America’s streets today; that the risks of Post Traumatic Stress Disorder (PTSD) 

and traumatic brain injury (TBI) appear to be at unprecedented levels in the population of 1.7 million servicemembers who have been deployed in the War on Terror; 

that there has been a resulting influx of veterans from previous theaters of war who 

are increasingly seeking VA services; and that the healthcare needs of aging veterans continue to grow. 

To assist with those needs, APA has many initiatives currently underway, including two Presidential Task Forces on the Needs of Military Servicemembers and 

Their Families, and the recently adopted ‘‘Blueprint for Change: Achieving Integrated Healthcare for an Aging Population’’, which is consonant with VA’s 

groundbreaking work on primary care integration. 


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APA’s Committee on Rural Health is addressing ways for psychologists to help extend services to veterans in rural areas where existing VA and Department of Defense (DoD) facilities are simply beyond the reach of patients. As well, APA’s public 

interest component works on issues of direct concern to VA, such as homelessness, 

military sexual trauma, and family violence. In education, we are creating training 

pipelines for specialty training of psychologists and other mental health professionals regarding soldiers’ pre and post deployment needs, through both the Center 

for Deployment Psychology (with the DoD) and in proposing expansion of our Graduate Psychology Education program. We also have recently provided testimony proposing funding increases over the Administration’s FY ’09 VA Medical and Prosthetic Research Account funding levels. 

Recruitment and the Psychology Workforce Within VHA 

As I indicated, VHA is the single largest employer of psychologists in the Nation, 

and has been for many years. Yet, VA continues to recognize the need to increase 

its psychology staffing levels in response to ever-increasing needs for services to veterans. As a result, VHA has added more than 800 new positions for psychologists since 

2005; thereby rapidly increasing the number of psychologists in the system to a current high of approximately 2,400, now surpassing the previous 1995 high of approximately 1,800 psychologists nationally. The 2,400 psychologists now employed by VA 

range from the GS–11 to GS–15 levels. 

The APA applauds VA for these tremendous and serious recent efforts to recruit 

additional psychologists into the system, and we have actively partnered with VA 

to promote the news of these openings, have attempted to assist with recruiting 

neuropsychologists (who are needed in increasing numbers due to TBI), and have 

worked to promote VA career choices by the newer generations of psychologists. 

I need to emphasize, however, that these increased psychology staffing levels are 

a very recent development over approximately the last year and a half only. Psychology staff levels were actually significantly BELOW 1995 levels until 2006. Moreover, the vast majority of new psychologist hires in VHA are younger, lesser experienced psychologists who have come into the system at the GS–11 to GS–13 levels. 

However, the contrast between the VA’s success in recruiting new professionals 

into the system versus VA’s retention and promotion of those existing VA psychologists with years of experience treating veterans is dramatic. 

For example, at the end of 2007, the number of GS–14s in the entire system nationally was no different than it was 12 years prior in 1995 (at 130 GS–14s total). 

Of additional concern to the APA is that the number of GS–15 psychologists nationally as of the end of 2007 (approximately 50) was actually considerably lower than 

the number of GS–15s in 1995. 

To the system’s credit, VA has also recognized and capitalized on the fact that 

the best source of recruiting new psychologists has been the Department’s own 

training systems. Over the past 2 years, approximately 75 percent of all new psychologist hires have been prior VA trainees. And, VA is rapidly increasing its funding of psychology training. In the 2008–2009 training year, VA has added approximately 60 new psychology internship positions and 100 new postdoctoral fellowship 

positions, spending approximately $5 million to do so. This will bring the total psychology training positions to approximately 620 per year nationwide. 

Retention of the Psychology Workforce 

Despite positive developments in recruitment, VA’s advancement and retention 

policies continue to be driven by outdated and overly rigid personnel and retention 

systems. In addition to hiring new staff, the VA needs to retain those existing psychologists who are qualified, possess specialized skills, and who are already acculturated within VHA. These psychologists are vital to service provision because of 

both their professional expertise and their knowledge of the system and its resources for veterans. 

1. Lack of Uniform Psychology Leadership Positions 

Since 1995, independent mental health discipline services at most facilities have 

been replaced with interdisciplinary Mental Health Service Lines. As a result, there 

has been a decrease in the number of discipline chiefs across the system. The dissolution of discipline specific services has left a clear leadership gap in terms of professional practice accountability, guidance on the proper use of professional skills, 

and promotion and oversight of profession-specific staff and pre-licensure training. 

Psychology remains the only major mental health discipline without an officially 

designated leader in every medical center, analogous to the Social Work Executive. 


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While there are a small number of ‘‘Chief Psychologists’’ remaining, the far more 

prevalent positions of discipline-based professional leadership are those such as ‘‘Supervisory Psychologist’’, ‘‘Lead Psychologist’’, or ‘‘Psychology Director’’. Notably, 

these positions are all too frequently unrecognized at the level of additional pay for 

the additional professional leadership responsibilities they entail. 

2. Inequitable Access to Key Leadership Positions 

Psychologists are also not represented equitably in all levels of leadership in the 

VA’s healthcare delivery system. In 1998, the Under Secretary for Health (USH) attempted to correct this situation with the issuance of VHA Directive 98–018, later 

reissued in 2004 as VHA Directive 2004–004, which stated that ‘‘it is important that 

the most qualified individuals be selected for leadership positions in mental health 

programs regardless of their professional discipline.’’ 

Unfortunately, the only requirement within the Directive was that announcements of VA mental health leadership positions not contain language that restricts 

recruitment to a specific discipline. As a result, this Directive has had little practical 

impact on the appointment of highly qualified psychologists to VA mental health 

senior leadership roles, particularly at medical school affiliated VA facilities. 

3. Serious Implementation Problems in Hybrid Title 38 

Psychologists remain the only doctoral healthcare providers in VA who are not included in Title 38. In late 2003, the Hybrid Title 38 system was statutorily expanded to provide psychologists (and a wide range of other non-physician disciplines) some of the same personnel and pay considerations as their physician counterparts. The hybrid model requires Professional Standards Boards to make recommendations on employment, promotion and grade for psychologists, and is still 

more subjective than a pure Title 38 program; unlike Title 38 where professionals 

are hired, promoted and retained based solely on their qualifications. 

The implementation of the new Title 38 Hybrid boarding process has been extremely variable and chaotic across the system. Many Psychologist leaders from facilities throughout the country have reported that their facilities and Veterans Integrated Service Networks (VISNs) have denied GS–14 and 15 promotions that have 

been recommended by the national boarding process. Even more frequent are reports of facilities and VISNs that have delayed or refused to forward boarding packets to the national board and/or have refused to reveal the results of the national 

board action. 

Informational missteps and technical problems have also plagued the national 

psychology boarding process. Just last month, VA Central Office (VACO) sent instructions to the field that eliminated the national cap on GS–14 levels for psychologists. However, these same instructions tied the award of GS–15 psychology positions to the facility’s level of complexity, making many senior psychologist leaders 

ineligible for grade increases commensurate with the scope and complexity of their 

actual duties. 

APA was optimistic that the Hybrid Title 38 system would modernize the pay system and foster greater retention of senior psychologists within the VHA system. 

Given that 5 years after its passage, implementation continues to be such a boondoggle, we are now seriously reconsidering our support for the Hybrid system, and 

considering instead a policy change to bring psychologists fully into the Title 38 system. The basic concept of Title 38 is ‘‘rank-in-person’’ rather than rank in position, 

basing rank and pay on one’s qualifications brought to the job rather than on some 

of the duties of the position. Hybrid 5/38 uses the procedures of Title 38 for recruitment, but not for rank and pay boards, preferring a mixture of Title 5 types of position descriptions, now re-titled in Title 38 language as ‘‘functional statements’’. The 

functional statements are used with Title 5 kinds of considerations, including scope 

of supervisory or managerial responsibilities, leaving no room for advancement in 

rank for senior psychology clinicians who are not part of medical staff. 

For example, efforts to make it easier for outstanding research clinicians to advance in rank have been virtually unsuccessful because in many cases it is written 

into their jobs as clinicians that research is part of their function; they are denied 

any special advancement for published papers, grants awarded from merit review 

bodies, etc. Indeed the bar of publications has been set so high that few of them 

have been able to advance in rank, again based on the kinds of measures one would 

have used under Title 5. 

Most physicians, under this rank in person concept, used to achieve a base pay 

equivalent to a GS–15, step 10. More recent changes to physician pay have resulted 

in psychiatric physicians being paid a minimum of $91,500 to a maximum of 

$225,000, with four levels of pay grade, each with a minimum and maximum, incorporating other elements such as ‘‘market pay’’ and ‘‘performance pay.’’ The result 


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is that the typical psychologist, depending upon locality tops out at about $101,000 

after 15–20 years of service (GS–13, step 10), while a senior physician typically may 

make 30 to 125 percent higher salary. 

Also, physicians have long had an annual bonus for board certification. Psychologists are now eligible for a one-time step increase, but only if they were to become 

newly board certified within a narrow window prior to, or since the inception of hybrid Title 5/38. Senior psychologists who have topped out in their grade (GS–13) are 

not eligible for anything other than a one-time award. 

Additional Factors Affecting Recruitment and Retention of Psychologists 

1. Medical Staff (Clinical) Privileges vs. Full Medical Staff Membership 

VA is based on a medical model, and doctoral psychologists are excluded from the 

decisionmaking process by being denied full medical staff privileges in many facilities, particularly those that are not affiliated with medical schools. Not being a 

member of the medical staff is to be a second class citizen. Psychologists are most 

typically ‘‘clinically privileged’’ practitioners, i.e., those who are not full members of 

the medical staff, and who are called ‘‘Licensed Independent Practitioners’’. But they 

have no formal say in hospital policy, and may not sit on the governing body of the 

medical staff in those facilities where they are not members. 

There are a number of important reasons to support psychologists having full 

medical staff membership throughout the VHA healthcare system. In recent years 

there has been a significant increase in the number of psychologists who have assumed leadership roles in important medical center programs. These include many 

of the new post traumatic stress disorder (PTSD), Recovery, Pain, Substance Abuse 

programs, and so forth. These psychologists are responsible for the supervision of 

various disciplines and provide direct clinical care for the medical center. These are 

certainly responsibilities that are consistent with full membership on the medical 

staff. In addition, many of the new Home Based Primary Care (HBPC) psychologists 

are working independently and away from the physical umbrella of the VA medical 

centers. They are doing important and demanding work in the veteran’s homes. 

Again, the level and complexity of work is what one would expect from a full member of the staff. Without membership, there is restricted input into many important 

decisions that impact programming and ultimately on patient care. 

2. Prescriptive Authority 

One of the most difficult current challenges for VHA is how to extend care into 

those areas, particularly in rural America, where VA facilities do not exist or are 

at great distance from the veteran. One option that VHA has long resisted, but 

should more carefully consider, is granting expanded authority for appropriately 

trained psychologists to provide both psychological and psychopharmacological care 

to veterans in these under-served rural areas. Experience in both States where licensed psychologists have this expanded statutory authority to prescribe (New Mexico and Louisiana), as well as a decade of data from the original DoD 

psychopharmacology program, have shown these practices to be safe and effective 

for the public. 

Both New Mexico and Louisiana, States with large rural populations, have passed 

laws to allow psychologists to prescribe. New Mexico, which passed its prescriptive 

authority law in 2002, and Louisiana, which passed its law in 2005, permit appropriately trained licensed psychologists with additional postdoctoral training in 

psychopharmacology to prescribe. These laws have been very successful, and to date 

nearly 50 psychologists prescribing in these States have written more than 40,000 

prescriptions without adverse incident. 

Furthermore, a Federal demonstration project set up nearly two decades ago has 

set a clear precedent that psychologists can successfully prescribe in a large Federal 

health system. The Department of Defense Psychopharmacology Demonstration 

Project (PDP) also proved that psychologists can be trained to prescribe safely and 

effectively. Begun in 1991, ten psychologists participated in the PDP, which was designed to train and use psychologists to prescribe psychotropic medications. These 

psychologists treated a wide variety of patients, including active duty military, their 

dependents and military retirees, with ages ranging from 18 to 65. 

The PDP was highly scrutinized. The American College of Neuropsychopharmacology (ACNP) conducted its own independent, external review of the PDP 

and in 1998 presented its final report to the DoD. Likewise, the General Accounting 

Office (GAO) issued a positive report on the PDP. Both reports repeatedly stressed 

how well the PDP psychologists had performed, and noted that with prescriptive authority, psychologists were able to offer holistic, integrative treatment, which includes psychotherapy and medication, where appropriate. 


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It is clear that already licensed doctoral psychologists are being trained to prescribe safely and effectively. The precedent for the VA system to recognize psychologist prescriptive authority is clear both from State action and the DoD’s program. 

In addition, APA Division 18 psychologists—Psychologists in Public Service—including those who serve in the VA, are already supporting training of a cadre of public 

service psychologists to be able to prescribe as recognition expands along with the 

need for services. The VA should begin to utilize such professionals to the full extent 

of their licensure and training. Psychologists are willing and able to help fill the gap 

and ease the strain on the VA health system particularly in rural areas. 

Summary and Examples 

Two dramatic, but not apparently unusual examples of how these problems are 

affecting services have recently crossed my desk. In one, a new hire, who happens 

to be a former State Psychological Association President and representative to 

APA’s Committee on Early Career Psychologists, was dismissed during his probationary year after being hampered in his abilities to effectively discharge his dual 

leadership duties as the facility’s new Local Recovery Coordinator as well as the 

Acting Supervisory Psychologist. In another facility, a more senior psychologist who 

was approved by the National Standards Board was denied locally for a GS–14 upgrade for her position as Psychology Program Manager and tendered her resignation 

on April 1st. 

APA considers the issues and problems addressed in this testimony as serious obstacles to making VA the workplace of choice for psychologists. Without clear advancement systems in place, VA faces critical long term recruitment and retention 

problems. As psychologists come to believe that there is little possibility for advancement, regardless of the level or complexity of responsibilities, fewer VA psychologists will be willing to accept positions of greater responsibility. In addition, high 

potential trainees whom the VA would like to recruit will increasingly see VA as 

a ‘‘dead end’’ for their careers, and will be attracted to other career options that offer 

more potential for advancement. 

Thank you for this opportunity to provide testimony today on behalf of the American Psychological Association. We stand ready to assist with the Committee’s work 

to further improve recruitment and retention of psychologists to assist in providing 

care to this Nation’s honored veterans. 

f 

Prepared Statement of Angela Mund, CRNA, MS, Clinical Director, 

University of Minnesota Nurse Anesthesia Area of Study, 

Minneapolis Veterans Affairs Medical Center, Veterans Health 

Administration, U.S. Department of Veterans Affairs, on behalf of 

American Association of Nurse Anesthetists 

Chairman Michaud, Ranking Member Miller, and Members of the Subcommittee: 

The American Association of Nurse Anesthetists (AANA) is the professional association that represents over 39,000 Certified Registered Nurse Anesthetists 

(CRNAs) across the United States. Over 500 CRNAs are employed by the Department of Veterans Affairs (DVA) healthcare system. We appreciate the opportunity 

to present our testimony to the Subcommittee. With our military personnel and Veterans’ access to safe and high quality healthcare our first priority, we want you to 

know that the profession of nurse anesthesia is working creatively and effectively 

with the Department of Veterans Affairs (DVA), in partnership with the U.S. Army, 

to improve its retention and recruitment of CRNAs, so that high quality anesthesia 

services remain available and accessible for our Nation’s Veterans. This work is crucial for several reasons; most importantly, because the anesthesia workforce needs 

in the DVA are increasing. Our request of the Committee is to understand these 

needs and to examine more closely the VA anesthesia workforce to ensure the 

safest, most cost-effective anesthesia services for our Veterans. 

CRNAs AND THE VA: A TRADITION OF SERVICE 

Let us begin by describing the profession of nurse anesthesia, and its history and 

role with the Veterans Administration health system. 

In the administration of anesthesia, CRNAs perform the same functions as anesthesiologists and work in every setting in which anesthesia is delivered including 

hospital surgical suites and obstetrical delivery rooms, ambulatory surgical centers, 

health maintenance organizations, and the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons. Today, CRNAs administer some 30 million anesVerDate Nov 24 2008 00:45 Mar 10, 2009 Jkt 043054 PO 00000 Frm 00046 Fmt 6604 Sfmt 6621 E:\HR\OC\43054.XXX 43054

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thetics given to patients each year in the United States. Nurse anesthetists are also 

the sole anesthesia providers in the vast majority of rural hospitals, assuring access 

to surgical, obstetrical and other healthcare services for millions of rural Americans. 

Since the mid-19th Century, our profession of nurse anesthesia has been proud 

and honored to provide anesthesia care for our past and present military personnel 

and their families. From the Civil War to the present day, nurse anesthetists have 

been the principal anesthesia providers in combat areas of every war in which the 

United States has been engaged. In May 2003, at the beginning of ‘‘Operation Iraqi 

Freedom,’’ 364 CRNAs had been deployed to the Middle East to ensure military 

medical readiness capabilities. For decades CRNAs have staffed ships, remote U.S. 

military bases, and forward surgical teams, often without physician anesthesiologist 

support. The U.S. Army Joint Special Operations Command Medical Team and 

Army Forward Surgical Teams are staffed by CRNAs. 

As our military personnel advance from active service to retired and Veteran status, their anesthesia care in VA facilities is provided predominantly by nurse anesthetists. In 12 percent of VA healthcare facilities, the necessary anesthesia services 

are provided solely by CRNAs, ensuring our Veterans the safe anesthesia care that 

they deserve and have earned. 

Our tradition of service to the military and our Veterans is buttressed by our personal, professional commitment to patient safety, made evident through research 

into our practice. In our professional associations, we state emphatically ‘‘our members’ only business is patient safety.’’ Safety is assured through education, high 

standards of professional practice, and commitment to continuing education. Having 

first practiced as registered nurses (RNs), CRNAs are educated to the master’s degree level, and some to the doctoral level, and meet the most stringent continuing 

education and recertification standards in the field. Thanks to this tradition of advanced education and clinical practice excellence, we are humbled and honored to 

note that anesthesia is 50 times safer now than in the early eighties (National Academy of Sciences, 2000). Research further demonstrates that the care delivered by 

CRNAs, physician anesthesiologists, or by both working together yields similar patient safety outcomes. In addition to studies performed by the National Academy of 

Sciences in 1977, Forrest in 1980, Bechtoldt in 1981, the Minnesota Department of 

Health in 1994, and others, Dr. Michael Pine, MD, MBA, recently concluded once 

again that among CRNAs and physician anesthesiologists, ‘‘the type of anesthesia 

provider does not affect inpatient surgical mortality’’ (Pine, 2003). Thus, the practice 

of anesthesia is a recognized specialty in nursing and medicine. Most recently, a 

study published in Nursing Research confirmed obstetrical anesthesia services are 

extremely safe, and that there is no difference in safety between hospitals that use 

only CRNAs compared with those that use only anesthesiologists (Simonson et al, 

2007). Both CRNAs and anesthesiologists administer anesthesia for all types of surgical procedures from the simplest to the most complex, either as single providers 

or together. 

NURSE ANESTHESIA PROVIDER SUPPLY AND DEMAND: SOLUTIONS 

FOR RECRUITMENT AND RETENTION IN THE DVA 

While both types of health professionals can provide the same high quality anesthesia care, CRNAs provide the DVA an additional advantage of cost-effectiveness. 

Consequently, both our Veterans and our VA health system are best served by policies and initiatives that secure adequate numbers of CRNA employees in the DVA. 

We believe that this Committee can help accomplish this objective by supporting 

nurse anesthesia education programs, both within the VA itself and in partnership 

with military and civilian schools of nurse anesthesia. 

It is essential to understand that while there is strong demand for CRNA services 

in the public and private healthcare sectors, the profession of nurse anesthesia is 

working effectively to meet this workforce challenge. The AANA anticipates growing 

demand for CRNAs. Our evidence suggests that while vacancies exist, the demand 

for anesthesia professionals can be met if appropriate actions are taken. As of January 2008, there are 108 accredited CRNA schools to support the profession of nurse 

anesthesia. The number of qualified registered nurses applying to CRNA schools 

continues to climb. The growth in the number of schools, the number of applicants, 

and in production capacity, has yielded significant growth in the number of nurse 

anesthetists graduating and being certified into the profession. The Council on Certification of Nurse Anesthetists reports that in 2007, our schools produced 2,021 

graduates, an 88 percent increase since 2002, and 1,869 nurse anesthetists were certified. The growth is expected to continue. The Council on Accreditation of Nurse 

Anesthesia Educational Programs (COA) projects the 108 CRNA schools to produce 

over 2,300 nurse anesthetists in 2008. 


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The number of VA anesthesia vacancies is causing us concern. We believe that 

they can be filled through creative partnership between the VA system and the profession of nurse anesthesia, and commitment by the DVA to effectively recruit and 

retain CRNAs. More than half of the VA nurse anesthesia workforce is over the age 

of 53, an age some years above the mean for all CRNAs nationally. The annual 

turnover and retirement rate among CRNAs within the VA has risen to about 19 

percent over the past few years and continues to rise as the workforce ages, more 

lucrative employment is offered in the private sector, and new graduates from 

CRNA educational programs find the VA employment and practice package comparatively uncompetitive. Currently, 24 stations show vacancies on public Federal 

job posting sites. However, we have reason to believe that the numbers of stations 

with actual vacancies is closer to 40, with staff vacancies either being left vacant 

for extended periods of time, or filled by contract personnel. Approximately 150 

CRNA slots in the DVA are being filled by contract personnel. 

As the nurse anesthesia profession is working to meet the demand for CRNAs 

generally, we believe that the DVA specifically can meet its CRNA recruitment 

needs by pursuing three strategies. First, DVA should expand its relationships with 

existing CRNA schools. Second, the DVA should expand its joint CRNA educational 

program together with the Department of Defense (DOD) health system. Third, the 

DVA should upgrade its recruitment, retention, and practice environment factors to 

make VA service more competitive with the private market for anesthesia services, 

within the context of the DVA’s mission. 

To a degree, some of these strategies are already under way and achieving results 

for the VA health system. A recent AANA survey shows our nurse education programs use some 70 VA hospitals and healthcare facilities as clinical practice education sites, helping to educate CRNAs, provide superior patient care, and aid the 

VA in recruiting nurse anesthetists. In addition, we recommend that the DVA pursue nurse anesthesia resource sharing programs with civilian CRNA schools 

through faculty exchange initiatives. 

Because nurse anesthesia is a safe and highly cost-effective means to secure anesthesia services for our Veterans, we have expressed concern that the DVA has introduced ‘‘anesthesiologist assistants’’ (AAs) to the VA health system, through new 

qualifications standards that do not require them to be licensed in any State, or subject to any State’s oversight or discipline, or to have graduated from an accredited 

educational program, or to have secured certification, or to be appropriately supervised by anesthesiologists in a manner consistent with AAs’ training as assistants. 

Though the DVA handbook VHA–1123 updated March 2007 authorizes anesthesiologists to delegate anesthesia care to unqualified, uncredentialed individuals, the 

VHA has not yet hired such individuals. There are other substantive concerns with 

the handbook. Our Veterans deserve better. We have requested the policy be withdrawn, and have met with the agency to promote our shared interest in ensuring 

our Veterans access to safe, high quality anesthesia care. 

U.S. ARMY-VA JOINT PROGRAM IN NURSE ANESTHESIA, FT. SAM 

HOUSTON, SAN ANTONIO, TX 

The establishment of the joint U.S. Army-VA program in nurse anesthesia education at the U.S. Army Graduate Program in Anesthesia Nursing, Ft. Sam Houston, in San Antonio, TX holds the promise of making significant improvements in 

the VA CRNA workforce, as well as improving retention of VA registered nurses in 

a cost effective manner. The current program utilizes existing resources from both 

the Department of Veterans Affairs Employee Incentive Scholarship Program (EISP) 

and VA hospitals to fund tuition, books, and salary reimbursement for student registered nurse anesthetists (SRNAs). 

This VA nurse anesthesia program started in June 2004 with three openings for 

VA registered nurses to apply to and earn a Master of Science in Nursing (MSN) 

in anesthesia granted through the University of Texas Houston Health Science Center. In the future, the program is granting degrees through the Northeastern University Bouve College of Health Sciences nurse anesthesia educational program in 

Boston, Mass. Due to continued success and interest by VA registered nurses for the 

school, the program increased to five openings for the June 2005 and 2006 classes. 

This program continues to attract registered nurses into VA service, by sending RNs 

the strong message that the VA is committed to their professional and educational 

advancement. In order to achieve the goal of expanding the program further, it is 

necessary for full funding of the current and future EISP to cover tuition, books, 

and salary reimbursement. 

The 30-month program is broken down into two phases. Phase I, 12 months, is 

the didactic portion of the anesthesia training at the U.S. AMEDD Center and 


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School (U.S. Army Graduate Program in Anesthesia Nursing). Phase II, 18 months, 

is clinical practice education, in which VA facilities and their affiliates would serve 

as clinical practice sites. In addition to the education taking place in Texas, the 

agency will use VA hospitals in Augusta, Georgia, increasing Phase II sites as necessary. Similar to military CRNAs who repay their educational investment through 

a service obligation to the U.S. Armed Forces, graduating VA CRNAs would serve 

a 3-year obligation to the VA health system. Through this kind of Department of 

Defense—DVA resource sharing, the VA will have an additional source of qualified 

CRNAs to meet anesthesia care staffing requirements. 

At a time of increased deployments in medical military personnel, VA-DOD partnerships are a cost-effective model to fill these gaps in the military healthcare system. At Ft. Sam Houston nurse anesthesia school, the VA faculty director has covered her Army colleagues’ didactic classes when they are deployed at a moment’s 

notice. This benefits both the VA and the DOD to ensure the nurse anesthesia students are trained and certified in a timely manner to meet their workforce obligation to the Federal Government as anesthesia providers. 

We are pleased to note that the Department of Veterans Affairs Acting Deputy 

Under Secretary for Health and the U.S. Army Surgeon General approved funding 

to start this VA nurse anesthesia school in 2004. In addition, the VA director has 

been pleased to work under the direction of the Army program director LTC Thomas 

Ceremuga, CRNA, PhD to further the continued success of this U.S. Army-VA partnership. With modest levels of additional funding in the EISP, this joint U.S. ArmyVA nurse anesthesia education initiative can grow and thrive, and serve as a model 

for meeting other VA workforce needs, particularly in nursing. 

We recently recommended that $400,000 be included in the FY 2009 appropriations to expand this joint educational program. 

LOCALITY PAY 

In order to meet demand for nurse anesthetists, each VA facility’s administrator 

may make use of existing locality pay structures as authorized and funded by Congress. Competitive salaries assist the DVA with retention of CRNAs to provide anesthesia services for our Nation’s veterans. Though providing competitive salaries for 

excellent employees is an ongoing challenge, using locality pay to keep personnel is 

most cost-effective. This is where Congress can help, by providing adequate funding 

for personnel through locality pay adjustments where base salaries are not sufficiently competitive with the local private market. Further, this Subcommittee 

should examine whether the 2004 authorization to expand incentive professional 

pays for physicians and nurse executives should also be applied to the recruitment 

and retention of nurse anesthetists, or, alternatively, whether other means should 

be pursued to lift the statutory cap that keeps VA nurse anesthetist compensation 

below local market levels. 

For several reasons, ensuring sufficient locality pay flexibility is in the interest 

of both our VA and our Veterans. The DVA faced a severe shortage of CRNAs in 

the early nineties, which was moderately corrected with the implementation of a locality pay system in 1991. In 1992, Congress expanded the authority to the local 

medical directors and allowed them to survey an expanded area to determine more 

competitive average salaries for CRNAs, which boosted pay and morale. Implementation of this expanded authority helped assist the DVA in making great leaps in 

retention and recruitment of CRNAs at that time. However, times and the local 

labor markets for healthcare professionals have continued to change. In the past few 

years CRNAs’ salaries have increased in the private sector, while the VA has not 

adjusted to these new salary rates. This means that in some markets the DVA locality pay system is no longer competitive with the private sector, and new nurse anesthetist graduates are choosing not to work in the VA health system. We believe that 

the VA would benefit by providing CRNAs competitive salaries in VA facilities and 

making use of effective locality pay adjustments, which reduces VA hospital administrators’ requirements for contracted-out services at higher rates. 

Though nurse anesthetists provide the lion’s share of anesthesia services to U.S. 

Department of Veterans Affairs (VA) healthcare facilities, the agency is facing a 

wave of retirements and having challenges recruiting CRNAs because the compensation it offers is below local market levels, a Government Accountability Office (GAO) 

report highlighted (‘‘Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists,’’ GAO–08–56, 12/13/2007) The GAO recommended that 

the VA apply its locality pay system more vigorously to recruit and retain nurse anesthetists. 

At the time the report was issued, the AANA issued a statement, saying, ‘‘The 

profession of nurse anesthesia is committed to caring for our Nation’s Veterans. 


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Nurse Anesthesia continues to be a safe, flexible and highly cost-effective means for 

the VA to ensure our Veterans the healthcare that they need and deserve. We look 

forward to continuing work with the Department of Veterans Affairs, the Congress, 

and the members of the Association of Veterans Affairs Nurse Anesthetists 

(AVANA) to help carry out the recommendations of this report.’’ 

The GAO found that VA medical facilities have had to temporarily close operating 

rooms or delay elective surgeries due to a shortage of CRNAs. While demand for 

CRNA services is increasing, the report says 26 percent of the VA’s CRNAs are projected to retire or leave the department in the next 5 years. The GAO said that the 

VA’s CRNA recruitment and retention challenges are caused primarily by the agency’s below-market compensation compared with local market conditions around the 

country. The GAO made its findings based on surveys of VA CRNAs, VA managing 

personnel in local VA facilities and at VA headquarters, and through other data 

sources. The report says the nurse anesthesia profession has been working effectively to meet high U.S. demand for anesthesia workforce by increasing the number 

of qualified practitioners graduating from accredited nurse anesthesia programs. 

The report recommended that the agency deploy and carry out its existing locality 

pay system to adjust salaries so that they are more competitive. Any locality pay 

system should be structured to set competitive salary levels for nurse anesthetists 

working in VA healthcare facilities. The DVA could implement a system that guarantees accurate surveys on pay are being conducted in a timely manner. This salary 

data will be used to adjust Nurse 1 (Step 1) to be competitive within the local market to assist VA facilities in hiring new nurse anesthesia graduates. 

Finally, with adjustments in the pay structure to include professional pays for recruitment and retention of CRNAs, VA facilities may well realize cost savings by 

contrast with other arrangements for securing anesthesia services. 

Recently, Senator Daniel Akaka (D-HI) introduced the Veterans’ Medical Personnel Recruitment and Retention Act of 2008 (S. 2969), and several of its provisions are intended to help the VA recruit and retain CRNAs to the VA healthcare 

system. We applaud Senator Akaka’s efforts to bring VA healthcare professionals’ 

pay closer to the private sector. Our first priority remains ensuring our Veterans’ 

access to a high quality of healthcare. The quality of healthcare services, and the 

qualifications expected of healthcare professionals, and the numbers of healthcare 

professionals, all together have bearing on the quality of life of our Veterans, and 

should be kept in mind in equal measure. 

CONCLUSION 

In conclusion, we recognize that the VA has nurse anesthesia staffing needs. 

Through an effective partnership with the nurse anesthesia profession, the DVA can 

help meet its future CRNA workforce requirements through three cost-effective 

models, which exist today and can be expanded. Our VA hospitals can serve as clinical practice sites for CRNA schools. Going one step further, the VA health system 

can pursue resource sharing and faculty exchange agreements with nurse anesthesia schools. Further still, the VA and DOD can share resources outright to educate nurse anesthetists for the Veterans and military settings alike, particularly 

with modest additional funding. This VA commitment to CRNA education helps secure the nurse anesthesia workforce our Veterans need, and attracts registered 

nurses into VA service, by sending the strong message that the VA is committed 

to RNs’ professional and educational advancement. Last, the VA should examine 

and improve the effectiveness of its recruitment, retention and practice environment 

for CRNAs. 

Thank you. If you have further questions, please contact the AANA Federal Government Affairs Office at 202–484–8400. 

f 

Prepared Statement of Jay W. Wommack, Founder, President and 

Chief Executive Officer, Vertical Alliance Group, Inc., Texarkana, TX 

Mr. Chairman and Members of the Committee, I am Jay Wommack, Founder, 

President and Chief Executive Officer of Vertical Alliance Group, Texarkana, TX. 

Thank you for the opportunity to express our views on the important issues relating 

to ‘‘Human Resources Challenges within the Veterans Health Administration.’’ 

As the Nation’s largest integrated healthcare system, the Veterans Health Administration (VHA), due in large to the efforts of this Committee has made impressive 

strides in improving the quality of care for our Nation’s Veterans. VHA has established itself as the ‘‘Trendsetter’’ in healthcare reform with programs such as the 

electronic medical records innovation. You are to be applauded. 


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In the way of introduction, I make no claim to being an expert in the Health Service arena; rather, over the past 9 years, I have been involved in the development, 

evaluation, and evolution of a comprehensive recruiting process for businesses that 

include health services. If I were to provide a title for my testimony today it would 

be ‘‘How to convert 40 percent of the applicants that come through VHA’s door into 

employees.’’ 

I recall shortly after college when I applied for my first ‘‘real’’ job, taking an hour 

or more filling out an application, turning it in and waiting patiently by the mailbox 

for weeks for a response that never came. And you can probably recall the excitement of receiving that four-inch thick mail order catalog. How you thumbed through 

every page, in my case mostly the toy section, and the anticipation and anxiety as 

you waited the 4 to 6 weeks for delivery—now I order online and it is at my door 

by the next day. Paper applications are fast going the way of the Pony Express and 

the new Sheriff in town is the Internet. Fundamental changes to the way we perceive and process applications must emerge if we are to meet the demands of tomorrow’s career markets. In today’s world, instant gratification is the norm. Not only 

do employers want quality employees, they want them now. Potential employees 

want the job of their dreams and they want it now. Applicants are all too often 

greeted with outdated processes that might have worked well in the sixties but fail 

to meet the demands of our high tech, Internet savvy society. A dramatic paradigm 

shift must take place to allow the conversion of new technologies into our recruiting 

process. We must consider how we merge today’s technology with this paperwork 

world. Applicants don’t want to wait for the hiring process to find the job of their 

dreams while their application is subjected to the confines of an electronic maze, 

they want immediate, personalized attention. With just a few changes in how we 

view and respond to these applicants our process can become more effective and efficient providing a lower cost per hire ratio. 

In 1999 Vertical Alliance Group, Inc. (VAG) began a long and thorough process 

to find out what works ‘‘BEST’’ in attracting and recruiting employees. With great 

efficiencies come great rewards. Operating on the premise that the Internet provides 

the most efficient/effective venue to attract and recruit quality employees VAG has 

created some proven processes that advance recruit productivity. Current statistics 

indicate the recruiting closing rate of U.S. businesses to be approximately 2 percent 

of all applications received. A forty percent (40 percent) closing rate doesn’t constitute the norm, however, these results can and have been attained utilizing the 

process we developed. Recruiting, training and retaining quality employees is paramount to the success of any business and directly affect it’s bottom-line. The amount 

of time, money and effort dedicated to recruiting/replacing staff can be reduced with 

just a few changes in our attitude and processes about how we recruit and what 

efforts are being made to retain quality employees. 

Our efforts have produced the following conclusions: 

• All levels of management must buy into and participate in the recruiting process. 

• Training of current personnel at all levels is an essential element if we are to 

change the dynamic of how we respond to leads and become more proactive in 

streamlining the hiring process. Conversion of Human Resource personnel from 

the world of paper processor to high tech ‘‘Sales Ambassadors’’ is essential to 

provide the immediate gratification demanded by today’s society. 

• We must provide timely follow-up to closure that ensure(s) prompt attention is 

given each lead. 

• We must improve the ‘‘quality’’ of prospective applications received. A success 

rate of 2 percent of ‘‘spammed’’ or database derived leads cost money and 

wastes time. 

Training is the essential element to a quality recruiting process. All levels of management must understand and value the recruiting process and recognize their role 

not only in recruiting but also the retention of highly qualified personnel. Understanding the direct response marketing strategy that includes an industry overview, 

how to rate/rank leads, selling skills, technique to close, selling points, the hiring 

cycle, are all necessary skills in providing a quality recruiting process. Knowledge 

of the current ‘‘shelf life’’ of applications is essential. In this competitive market, 

often the first quality response, usually within minutes not hours, days or weeks 

wins the deal. Human Resource personnel who are properly trained, highly motivated and who understand the value of this process provide the largest ‘‘bang for 

the buck’’ in recruiting and maintaining a strong workforce. 

Understanding the benefits and limitations of modern technology and the balance 

between them can also improve your odds in closing the deal. The ‘‘human’’ element 


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is still one of vital importance in the process. First impressions still count. Potential 

employees still want a response from a real person, not a computer. In the words 

of Walt Disney, ‘‘There is no magic in magic, just details.’’ Timely, polite, professional communication will work magic in the recruiting process. 

Massed, unranked or inappropriately filtered leads provide ‘‘volume’’ but lack 

‘‘quality’’ and generate large amounts of paperwork generally resulting in minimal 

success. Quality leads, appropriately ranked by source first allow Human Resource 

personnel to come out of the paper processor role and become more proactive in the 

recruiting process. Targeted leads focused on essential hiring criteria provide optimal potential for successful closure and lower cost for hire rates. 

In an agency the size of VHA arguments can be made pro and con between centralized and decentralized recruiting processes. Each has its own unique values and 

barriers. Training of all personnel in their respective roles in the recruiting and retention process will provide a more prolific recruiting effort on behalf of the VHA. 

There are a number of issues and complexities that challenge our Human Resource efforts . . . But the good news is, there are solutions. Amy Gruver, Call Center Team Leader for Swift Transportation Company, one of the largest trucking 

companies in America, has stated that the VAG process has resulted in their lowest 

cost per hire rate. Small businesses to Fortune 500 companies have effectively implemented and assimilated this process with phenomenal success saving valuable 

resources. 

Mr. Chairman, this concludes my remarks. I would be happy to answer any questions that you or other Members of the Subcommittee may have at the appropriate 

time. 

f 

Prepared Statement of Fred Cowell, Senior Associate Director 

for Health Analysis, Paralyzed Veterans of America 

Chairman Michaud, Ranking Member Miller, and Members of the Subcommittee, 

on behalf of the Paralyzed Veterans of America (PVA), I am pleased to be here today 

to offer our views concerning the ‘‘Human Resource Challenges within the Department of Veterans Affairs.’’ 

PVA’s primary concern, and the basic reason for our existence, is the health and 

welfare of our members and of our fellow veterans. The thousands of VA healthcare 

professionals and all of those individuals necessary to support their efforts are at 

the core of VA’s primary mission. These individuals serve on the front line every 

day, caring for America’s wounded veterans from Iraq and Afghanistan and seeing 

to the complex medical needs of our countries older veterans from previous wars. 

PVA believes thatVA’s most important asset is the people it employs to care for 

those who have served our Nation. 

Mr. Chairman, the Subcommittee’s interest in the issues concerning VA 

healthcare personnel is well placed and timely. Congress must assist VA’ efforts to 

recruit and retain its corps of healthcare professionals as the demand for healthcare 

increases because of today’s wars and the aging of the veteran population from previous wars. Currently, the Nation is experiencing serious short falls in its supply 

of physicians, nurses, pharmacists, therapists and psychologists. Competition for experienced medical personnel and newly licensed professionals is keen. 

PVA believes that Congress must take the lead in revamping outdated personnel 

policies and procedures (salaries, benefits, and working conditions) that may place 

VA at a disadvantage in today’s labor market and will prevent VA from becoming 

the medical-care employer of choice in the future. PVA also believes that the broken 

VA appropriation process, which delays VA funding, is a major barrier to VA’s 

healthcare professional recruitment process. 

America’s National Nurse Shortage 

The United States is currently in the tenth year of a critical nursing shortage 

which is expected to continue through 2020. The shortage of registered bed-side 

nurses and registered nurse specialists is having an impact on all aspects of acute 

and long-term care. America’s nursing shortage has created nurse recruitment and 

retention challenges for medical-care employers nationwide and is making access to 

quality care difficult for consumers. 

Three national issues are directly contributing to America’s national nursing 

shortage. First, the number of new nursing students entering nursing education programs is insufficient to meet rising medical care demand. Second, the number of 

nursing students seeking admission to nursing schools is restricted because of a lack 

of qualified nursing educators. According to the American Association of Colleges of 


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1 National Commission on VA Nursing 2002–2004, Final Report, Caring for America’s Veterans: Attracting and Retaining a Quality VHA Nursing Workforce. 

Nursing, 38,400 nursing school applicants were turned away because of a lack of 

faculty. Third, a large percentage of the Nation’s nurse workforce is nearing retirement and will soon need to be replaced. 

The current and emerging gap between the supply of and the demand for nurses 

may adversely affect the VA’s ability to meet the healthcare needs of those who 

have served our Nation. According to VA, it employs more than 64,000 nursing professionals, and has one of the largest nursing staffs of any healthcare system in the 

world. Of that 64,000, VA has 43,000 registered nurses, 12,000 licensed practical 

nurses, and 9,000 nursing assistants. VA also says that approximately 4,300 nurses 

retire or leave each year. VA must be able to recruit the best nurses, and retain 

a cadre of experienced, competent nurses. Providing high quality nursing care to the 

Nation’s veterans is integral to the healthcare mission of VA. 

Like other healthcare employers, VA must actively address those factors known 

to affect recruitment and retention of nursing personnel such as: fair compensation, 

professional development, work environment, respect and recognition, underlying 

issues of sucessful VA nurse recruitment and retention. Failure to do so will undermine the quality of VA care and will jeopardize the health of our veterans. 

Mr. Chairman, The National Commission on VA Nursing submitted its final report to then VA Secretary, Anthony J. Principi on March 18th, 2004.1 The report 

titled, Caring for America’s Veterans: Attracting and Retaining a Quality VHA Nursing Workforce is as vital today as it was then. 

PVA supports the following recommendations contained in that report 

and believes they serve as a sound template for improvements to VA’s policies and procedures that govern its healthcare workforce. The recommendations of the National Commission on VA Nursing were: 

Leadership 

• The facility nurse executive should have line authority, responsibility, and accountability for nursing practice and personnel. 

• The facility nurse executive should be a member of the executive body at VISN 

and facility levels. 

• The facility nurse executive should be accountable for (a) the effective performance of nurse managers, (b) leadership development of all nursing staff, (c) development and implementation of clinical leadership roles at the point of care, 

and (d) compliance with standardized Nurse Professional Standards Boards 

(NPSB) protocols. 

• VHA should clearly define Nurse Qualification Standards to facilitate consistent 

interpretation across VA’s system of care. 

Professional Development 

• VHA should structure career development opportunities to assure that every 

nurse in VHA can actualize his/her goals within one or more career paths with 

the opportunity for professional growth and advancement. 

• VHA should establish policy guidelines for schools of nursing comparable to the 

medical school model and actively promote nursing school affiliations. 

• VHA should assure that VA’s Health Professionals Educational Assistance Program is funded and available nationwide. 

Work Environment 

• VHA should develop, test, and adopt nationwide staffing standards that assure 

adequate nursing resources and support services to achieve excellence in patient 

care. 

NOTE: PVA believes that nurse staffing standards must consider the 

acuity level of patients for these standards to be meaningful. 

• VHA should review and adopt appropriate recommendations outlined in the Institute of Medicine report , Keeping Patients Safe: Transforming the Work Environment of Nurses, to determine specific strategies for implementation across 

VHA. 

Respect and Recognition 

• VHA should expand recognition of achievement and performance in its nursing 

service. 

• VHA should create a sense of value and culture of mutual respect for nursing 

through all levels of VHA to include physicians and other colleagues, management, and stakeholders. 


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2GAO Report April 9, 2008, VA Health Care: Recruitment and Retention Challenges and Efforts to Make Salaries Competitive for Nurse Anesthetists, GAO–08–647T. 

Fair Compensation 

• VHA should amend Title 38 to establish procedures for assuring that RN locality pay policies are competitive with local RN employer markets. 

NOTE: PVA supports specialty nurse pay for VA nurses working in VA’s 

specialty care areas such as: spinal cord injury rehabilitation and sustaining care, blind rehabilitation, mental illness and traumatic brain 

injury. 

• VHA should change hiring and compensation policies to promote recruitment 

and retention of licensed practical nurses and nursing assistants. 

• VHA should strengthen its human resources systems and departments to develop an active hiring and recruiting process for nursing staff that is consistent, 

to the extent possible, across facilities and VISN’s. 

Technology 

• VHA should give priority to the continued rollout of the VA Nursing Outcomes 

Database (VANOD) as the repository for nursing performance standards and 

the evaluation of effective patient care delivery models. 

• VHA should engage experts to evaluate and redesign nursing work processes to 

enhance patient care quality, improve efficiency, and decrease nurse turnover 

through the use of technology. 

• The Agency for Healthcare Research and Quality (AHRQ) and VHA should 

partner in applying findings from information systems and technology research 

projects into patient care delivery. 

Research and Innovation 

• VHA should establish a Center for Excellence in Quality Nursing Care to create 

and implement a research agenda consistent with VHA mission. 

Mr. Chairman, while these recommendations for VA improvement were directed 

toward VA’s Nursing Service PVA believes that they have broad application to VA’s 

entire healthcare workforce. 

Specialty Pay for VA’s Specialized Services Nurses 

PVA would very much appreciate the committee’s consideration of providing specialty pay for nurses providing care in VA’s specialized service programs such as: 

spinal cord injury/disease (SCI/D), blind rehabilitation, mental health and brain injury. 

Mr. Chairman, veterans who suffer spinal cord injury and disease require a cadre 

of specialty trained registered nurses to meet their complex initial rehabilitation 

and life-long sustaining medical care needs. PVA’s data reveals a critical shortage 

of registered nurses who are providing care in VA’s SCI/D center system of care. 

The complex medical and acuity needs of these veterans, makes care for them extremely difficult and demanding. These difficult care conditions become barriers to 

quality registered nurse recruitment and retention. Many of VA’s SCI/D nurses are 

often placed on light duty status because of injuries they sustain in their daily 

tasks. When this happens it becomes a significant problem because it places additional patient care responsibility on those SCI/D nurses not on light duty. PVA believes SCI/D specialty pay is absolutely necessary if nurse shortages are to be overcome in this VA critical care area. 

We strongly encourage your committee to create a Title 38 specialty pay provision 

that will assist VA’s efforts to recruit and retain nurses in these specialized areas. 

PVA is eager to assist Committee staff in developing legislative language that will 

create specialty pay for VA nurses working in these critical care areas. 

Nurse Anesthetists 

VA is currently facing serious challenges to the recruitment and retention of Certified Registered Nurse Anesthetists (CRNA) who provide the majority of anesthesia 

care for veterans receiving care in VA medical facilities. GAO has reported that VA 

medical facilities have current challenges recruiting and retaining VA CRNAs and 

that these facilities will likely face challenges in retaining CRNAs over the next 5 

years due to the number of VA CRNAs projected to retire from or leave VA.2 The 

GAO further reported that their surveys of VA officials indicated that low VA salaries were the major barrier to VA’s recruitment and retention efforts for this critical 

nursing skill. 


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3Statement before the Senate Committee on Veterans Affairs, April 9, 2008, Making VA the 

Workplace of Choice for Health Care Providers, by John A. McDonald, M.D., Ph.D. Vice President for Health Services and Dean of the University of Nevada Medical School and member of 

the Association of American Medical Colleges, Veterans Affairs—Deans Liaison Committee. 4Statement before the Senate Committee on Veterans Affairs, April 9, 2008, Making VA the 

Workplace of Choice for Health Care Providers by Valerie O. Meara, N.P. Professional Vice 

President, AFGE Local 3197 VA Puget Sound Health Care System, Seattle, Washington. 

VA Physicians 

PVA is concerned about the VA’s current ability to maintain appropriate and adequate levels of physician staffing at a time when the Nation faces a pending shortage of physicians. Recent analysis by the Association of American Medical Colleges 

(AAMC) indicates the United States will face a serious doctor shortage in the next 

few decades.3 The AAMC goes on to say that currently, ‘‘744,000 doctors practice 

medicine in the United States, but 250,000—one in three are over the age of 55 and 

are likely to retire during the next 20 years.’’ The subsequent increasing demand 

for doctors, as many enter retirement, will increase challenges to VA’s recruitment 

and retention efforts. 

Mr. Chairman PVA has serious concerns regarding VA’s current and future ability 

to match or exceed private sector physician salaries. Additionally, PVA believes that 

VA’s recruitment efforts are hampered because VA’s Education Debt Reduction Program (EDRP) is limited to $49,000 spread out over 5 years of service. The average 

medical education indebtedness has climbed to over $140,000 in 2007, therefore the 

limited VA EDRP awards fail to provide an adequate incentive for VA recruitment. 

PVA is also concerned that the P.L. 108–445, the Department of Veterans Affairs 

Personnel Enhancement Act, is being manipulated by facility management to reduce 

operation costs. The American Federation of Government Employees (AFGE), AFLCIO testified before the Senate Committee on Veterans Affairs that, ‘‘At many VA 

facilities, management has imposed improper performance criteria that determine 

bonuses based on factors beyond the practitioners control, such as missed appointments.’’4 The AFGE goes on to say that annual physician performance pay awards 

under this law have been inconsistent and unjustifiably lower than the maximum 

amounts set by Congress. 

The Independent Budget veterans service organizations (IBVSOs) believe that appropriate committees should use their oversight authority to study the impact of 

P.L. 108–445 on recruitment and retention of VA physicians and dentists. 

VA Psychologists 

According to the American Psychological Association (AAPA), VA is the largest 

single employer of psychologists in the Nation. Congress and VA have recognized 

the need to increase the number of psychologists and have added more than 800 

new psychologists since 2005, thereby raising the number of psychologists in the VA 

system to approximately 2,400. The demands placed on VA’s mental health service 

have increased dramatically because of the wars in Iraq and Afghanistan (OIF/ 

OEF). However, it should be noted that these increased psychology staffing levels 

are a recent development. Since the vast majority of new psychologist hires in VA 

are less experienced professionals, VA must ensure they are properly trained and 

supervised. VA must also strive to retain and promote its more experienced psychologists in order to meet new training and supervision requirements. 

Despite VA’s positive recruitment efforts, VA’s advancement and retention policies 

continue to be driven by outdated and overly-rigid personnel and retention mandates. PVA urges the Subcommittee to utilize its oversight authority to investigate 

VA’s on-going psychologists recruitment efforts to determine if VA is providing adequate levels of mental healthcare to meet the demands imposed by OIF and OEF 

while ensuring that adequate treatment opportunities continue to exist for veterans 

with prior service. 

Summary 

Mr. Chairman, the Veterans Health Administration has made great strides over 

the last decade to improve the quality of care it provides to our Nation’s veterans. 

Despite these gains, VA now finds itself in a precarious situation if it expects to retain its position as a vastly improved healthcare system. Challenges associated with 

maintaining a highly qualified medical care workforce are a major issue for VA. 

Competition to hire medical care professionals, during a national period of low supply, is making it more-and-more difficult for VA to successfully recruit and retain 

qualified personnel. 

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ter utilize existing policy provisions that provide locality pay, premium and overtime 

pay, create flexible work schedules, relieve restrictions on mandatory overtime, and 

fully fund its excellent educational programs such as the Education Debt Reduction 

Program and the National Nursing Education Initiative. 

Mr. Chairman, PVA believes that Congress must assist VA’s employment efforts 

by up-dating provisions of Title 38 that will enhance VA’s competitive position as 

it vies to attract healthcare professionals to its ranks. Additionally, Congress must 

embrace a VA appropriation process that promptly funds the VA healthcare system 

so VA management can be confident that resources are available to support a 

health-care workforce that can meet the medical care demand of a growing veteran 

population. 

Mr. Chairman, this concludes my remarks. I will be happy to attempt to answer 

any questions you or Members of the Subcommittee may have. 

f 

Prepared Statement of Cecilia McVey, BSN, MHA, RN, Associate Director 

for Patient Care/Nursing, Veterans Affairs Boston Healthcare System, 

Veterans Health Administration, U.S. Department of Veterans Affairs, 

and Immediate Past President, Nurses Organization of Veterans Affairs 

Mr. Chairman and Members of the Committee on Veterans’ Affairs Subcommittee 

on Health, the Nurses Organization of Veterans Affairs (NOVA) would like to thank 

you for inviting us to present testimony on Human Resource issues in the VA. 

I am Cecilia McVey, BSN, MHA, RN, Associate Director for Patient Care/Nursing 

at the VA Boston Healthcare System and am here today as the Immediate Past 

President of NOVA. NOVA is the professional organization for registered nurses employed by the Department of Veterans Affairs. 

NOVA respects and appreciates what our labor organizations, such as AFGE and 

NAGE, do for VA nurses. NOVA clearly deals with VA on RN professional matters, 

not working conditions for which VHA RNs have their union representatives. Because this Committee has invited NOVA to share its views on this bill, however, 

I am here to offer the following observations. 

The Veterans Health Administration (VHA) is the third largest civilian employer 

in the Federal Government and one of the largest healthcare providers in the world. 

VHA is facing significant challenges in ensuring it has the appropriate workforce 

to meet both current and future workforce needs. This workforce is critical to ensure 

we are able to provide the care our Nation’s heroes deserve. These challenges are 

further exacerbated by an aging workforce in general and in nursing specifically and 

the high number of employees’ retirement eligible each year. 

Nursing and other Medical Center workforce members are dependent on timely 

and efficient recruiting. Human Resources Departments across VHA are not able to 

function optimally due to systems that have not kept pace with private sector recruitment abilities. 

Although there are numerous barriers to timely and efficient recruiting the following three are the top three: 

1. Although certain pay setting flexibilities do exist, such as recruitment bonuses/ 

retention allowances, above minimum entry rates, and the special rate authority, additional pay flexibilities are needed in order for VA to be able to successfully compete for the best candidates in the marketplace. The current general 

schedule and locality pay system which works hand in hand with the classification system is antiquated, cannot respond quickly enough and has a number 

of major barriers. For example: 

a. Retention allowances. 

1. They are not considered base pay for benefits such as retirement and life 

insurance. Candidates declined positions based on this limitation. 

b. Special pay rates. 

1. There are restrictions on how far the pay table can be expanded. 

2. You cannot use special rates to address recruitment/retention issues of 

a subgroup within an occupation 

3. Approval process for special rates is too slow to address current market 

conditions. 

4. The major focus of the criteria is whether you are getting qualified candidates to apply and not whether the candidates are highly qualified. 

c. Above minimum rates. 


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1. Allows manager to appoint the applicant above the minimum step. There 

are many situations where the manager needs to offer a highly qualified 

candidate more money than the existing experienced staff. There is no 

mechanism to increase the pay of the existing staff to maintain pay parity. 

2. The application process (how to apply) is too cumbersome and very confusing for those in the private sector who are used to a much faster and 

simpler process. Staffing Specialists must help many of the would-be applicants to navigate through the maze of the Federal application process. 

Applicants are frustrated by the duplication of information that they are 

required to provide, such as the information on Federal application for 

employment, information for background investigations, and 

credentialing. The enormous amount of paperwork, data base entries, 

and checklists associated with fulfilling all of the hiring requirements 

further delays the process. This leads to hiring additional FTEs to manage the processes. 

3. A consistent theme across the country is that applicants are looking for 

money for professional development not just in clinical occupations but 

administrative as well. Tuition reimbursement is limited to a few select 

occupations at this time such as Nurses. 

Some suggested policy changes recommended are as follows: 

1. More positions should be converted to Excepted Service, i.e., hybrid Title 38 

such as Nursing Assistants, Health Technicians, Medical Support Assistants, 

Radiation Safety Officers, and Information Technology Specialists, for example. 

Due to the constraints associated with recruiting through the Delegated Examining Units, the process is often too difficult and generally does not provide a 

list of ‘‘highly qualified candidates’’ and discourages potential hires. 

2. More pay flexibilities should be provided. Pay reform similar to the Physician 

pay reform where there is a market pay component would provide the needed 

flexibility for VA facilities at the local level. Another option would be to provide 

legislation that would address the barriers in paragraph 1 above. 

3. Classification Standards are in need of review and revision. Many of them are 

too old and no longer reflective of the types of duties and responsibilities that 

are typically performed. Given that these are used to determine the pay, they 

often serve as a barrier to appropriate and effective pay setting. 

4. Given the sizeable numbers of employees at or near retirement age, succession 

planning is becoming increasingly more important, especially for critically important positions. In order to successfully transition workload from retirees 

who possess a wealth of experience to their successors; transitional recruitment 

is required, which can take up 3 to 6 months of addition FTE per situation. 

One other critical issue of concern relates to the impact on patient care if 38 

U.S.C. 7422(b) exclusions were to be repealed. Some of the issues that I foresee 

would have a negative impact on the care of our Veterans include the following: 

• RN reassignment decisions made on the basis of clinical competence. 

• Performance appraisals/proficiency reports. 

• Fitness for duty issues as determined by Professional Standards Boards. 

• Clinical competence issues as determined by Professional Standards Boards. 

• Disciplinary and major adverse actions based on patient care or clinical competence issues. 

Determination of clinical competence is best reserved for those responsible in ensuring that quality patient care is delivered. Our veterans deserve the best that VA 

has to offer, and although the majority of our employees are excellent, there are a 

few marginal performers who put patient safety at risk. Moreover, clinical supervisors and managers must retain the authority to make clinical decisions such as 

which personnel are best suited for particular assignments and the appropriate staff 

mix for a given clinical setting. 

Inherent in bargaining is the element of timeliness. If an employee needs to be 

removed from direct patient care or if providers’ hours must be extended to meet 

growing patient care needs, those changes must be made immediately and cannot 

wait for the completion of protracted negotiation. National Level bargaining on policy or program changes is currently taking 120 days or longer. Local bargaining usually takes less time but still can result in delays, despite the best of intentions. If 

clinical matters were subject to bargaining, critical clinical programs such as extending the hours of mental health clinics or mandating traumatic brain injury 


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training for all providers could not be implemented for months, which would unacceptably put patients at risk. 

VHA has been a leader in healthcare and has earned an excellent reputation as 

one of the best healthcare providers in the country. In order to continue this reputation, VHA staff will need to have new skills and competencies to treat this new generation of Veterans. Nimble and flexible HR processes are critical to VA’s future 

success. Thank you, Mr. Chairman and Members of the Subcommittee, for the opportunity 

to testify here today about these important personnel issues. 

f 

Prepared Statement of Adrian M. Atizado, 

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 

human resources challenges within the Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA). 

The human capital needs of VHA are driven by needs of the population VA serves. 

VA is experiencing a gradual slowdown in the growth of its enrollees due to declining veteran population, mortality in the Priority 8 enrollee population since the suspension of enrollment, and deaths in the pre-enrollee population. New enrollments 

of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans 

do not reverse the trend. Further, the reliance and utilization rates of veteran enrollees from prior conflicts are more established and better defined than the medical 

care consumerism of the OEF/OIF enrollee population. 

A number of undefined variables, such as duration of the conflict, demobilization 

requirements, and impact of outreach efforts, will influence the number and types 

of services that VA will need to provide OEF/OIF veterans. What is known today 

is that the current OEF/OIF veterans appear to have different utilization patterns 

than the rest of the VA enrollee population, needs that will demand greater flexibility in human resource management within the VA. Specifically, initial findings 

indicate OEF/OIF enrollees use half as much inpatient surgery and acute medicine, 

but it is expected that they will need three times the number of PTSD residential 

rehabilitation services, and have greater needs for physical medicine, prosthetics 

and outpatient psychiatric and substance abuse services. Correspondingly, enrollees 

from previous wars making up the vast majority of the population continue 

transitioning to higher enrollment priorities, and the aging morbidity of this population are driving the type and intensity of healthcare needs—even with the acknowledged declining reliance on VA once they qualify for Medicare. 

In the general civil service arena, the Office of Personnel Management (OPM) estimates about one-third of full-time government workers will retire by 2012, but 

some occupations are more sensitive to external forces and agency initiatives than 

others. 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 was 48 years. It estimated that by the end of 

2012, approximately 91,700 VHA employees, or 44 percent 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. In addition, a significant number of healthcare professionals in leadership positions would also be eligible to retire by the end of 2012. With regard to 

the three mission critical occupations—registered nurse, pharmacist and physician, 

a startling finding in the report concluded that 97 percent of VA nurses in pay band 

‘‘V’’ positions would be eligible to retire, and that 56 percent were expected to retire; 

and, that 81 percent of VA physicians in pay category 16—including many current 

Chiefs of Staff, would be eligible to retire, with 44 percent projected to actually retire from Federal service. 

Furthermore, the supply of healthcare providers poses an added hurdle for VA to 

be a patient-centered and integrated healthcare organization for veterans providing 

excellence in healthcare, research, and education; an organization where people 

choose to work; an active community partner and a back-up for national emergencies. In recognition, VA’s more recent commonly used description is that, ‘‘[t]here 

is a growing realization that the supply of appropriately prepared healthcare 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 

professional schools is not growing fast enough to meet the projected future demand 

for healthcare providers.’’ 


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Without question, recruitment, management, and providing direction for VA employees on such issues as compensation, hiring, performance management, and organizational development are critical to the success of VHA’s mission to provide safe, 

high quality healthcare services to sick and disabled veterans. While the most recent actions by Congress to affect the compensation package VHA may offer to prospective employees necessitates additional implementation oversight, an equally important problem within the realm of recruitment that requires attention is the Federal hiring process itself. 

Hiring a new wave of Federal employees to succeed those that leave is paramount 

given the frequent civil-service hiring freezes of the past 2 decades due to cross-government rescissions and dictated ‘‘management efficiency’’ savings, inadequate funding levels, and the unpredictable nature of the discretionary appropriations process. 

Moreover, the passive approach to recruiting applicants by Federal agencies including VA puts themselves on unequal footing compared to the recruitment and retention programs used by many competitive private employers. With over 100,000 

healthcare trainees receiving clinical learning experiences annually in VA facilities, 

hiring from this pool should provide VHA with an increased advantage over private 

healthcare facilities. Unfortunately, there is the perennial and widely acknowledged 

complaint by applicants for Federal employment about cumbersome Federal hiring 

procedures and practices, which require too much time and excessive paperwork. Of 

those who do submit applications, many say they never receive feedback from agencies of interest. 

According to a survey conducted by the Merit Systems Protection Board (MSPB), 

supervisors and upper-level new employees reported that the hiring process is complex and takes too long. The most recent MSPB survey of entry-level hires and 

upper-level hires showed that substantial numbers had to wait 5 months or longer 

before being hired—much too long to expect a high-quality applicant to wait. These 

findings harken back to the 2002 survey indicating an average of about 3 months 

are required for the government to hire anyone, while 70 percent of college students 

say that they are unwilling to wait more than 4 weeks for a job offer. 

OPM has publicly acknowledged this problem in Federal hiring and has agreed 

that the process has become cumbersome. To address this, it has urged Federal 

agencies to take advantage of recent laws that encourage quick hiring decisions and 

permit the use of bonuses to recruit and retain Federal employees. Unfortunately, 

a myriad of rules and procedures are still in place to restrict the use of these tools. 

These restrictions in Federal hiring decisions were designed to ensure equity, consistency, and accountability, while also protecting against fraud, waste and abuse. 

This design does not compete well with private sector recruitment practices. 

While Federal job applications are only the first tedious part of the process, agencies require approval from their personnel departments, which in turn cannot go beyond the level of appropriated or designated funds. If the agency, department, or 

facility does get approval, its managers must produce a proper position description, 

get the vacancy announcement approved and posted, rate the applicants, interview 

the candidates, get higher-level approval for the hire, then conduct boarding, and 

finally complete any required background checks, (and for professionals, complete 

credentialing and privileging). Each step adds more time to the process. In some 

cases security and background checks have caused several months delay due to increased security requirements. Candidates for the top tier career appointments to 

the Senior Executive Service (SES must pass yet another review board, composed 

of SES members. The 5-month average for the government to hire anyone is infeasible for many applicants—especially younger job-seekers. 

VA recently testified on streamlining its cumbersome hiring process, stating the 

Human Resource Committee of the VHA National Leadership Board chartered a 

workgroup last year 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 that could be streamlined. The recommendations were piloted in Veterans Integrated Service Network (VISN) 4 (generally, Pennsylvania) with the implementation and results of the pilot rolled out nationwide. During the spring and summer of 2008, training in systems redesign will 

be offered nationally at Human Resources Cluster meetings. At these sessions, VA 

testified it will focus on new strategies and systems redesign elements that can be 

used to help meet the daily challenges of attracting and retaining critical healthcare 

professionals. 

In addition to time, there is often poor communication between Federal managers 

and HR professionals on the qualities and skills needed in a candidate. Attrition of 

experienced VHA human resources employees has had a direct impact on the quality of recruitment and retention efforts as well as providing needed assistance to 

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viders. In the end, those individuals who make it to the end of this process are often 

not the optimum candidates, nor the best qualified for the position. In fact, in the 

2006 Federal Human Capital Survey, less than half of government workers said 

that their work unit is able to hire people with the right skills. 

VHA’s workforce is covered under Title 5, Title 38, and Congress has provided 

VHA a unique Title 38 ‘‘hybrid’’ authority, combining elements of both titles. As the 

greater majority of VHA employees fall under Title 38 and Title 38 hybrid systems, 

personnel rules under both were designed to allow greater flexibility and expedite 

VHA’s hiring and promotion processes. The Title 38 hybrid model requires Professional Standards Boards to make recommendations on employment, promotion and 

grade. This model is viewed as more subjective due to the level of transparency than 

Title 38, where professionals are hired, promoted and retained based solely on their 

professional qualifications. Moreover, the reality of the hiring and promotion processes under Title 38 hybrid is facing extraordinary delays particularly in the boarding process across healthcare disciplines from nurses to psychologists. 

The Federal hiring process is so daunting that it often reinforces applicants’ worst 

fears of government as an ineffective, unresponsive and incomprehensible bureaucracy. Only by insisting that agencies make recruiting talent a top priority and that 

both agency leaders and managers be held responsible for results, can we ensure 

that the government recruits the talent it needs to meet the challenges ahead. A 

simple practice (but time consuming due to inadequate VHA human resources staffing) that could be employed is to ensure that the human resources staffs responsible 

for recruiting applicants provide some meaningful and timely feedback to job applicants. Feedback, which puts some personal touch to an impersonal process, can help 

maintain applicants’ interest in the agency as well as throughout a hiring process 

that can be lengthy as I have indicated. 

Again, we thank you for this opportunity to testify. This concludes my testimony, 

and I will be happy to address any questions from the Chairman or other Members 

of the Subcommittee. 

f 

Prepared Statement of Joleen Clark, Chief Officer, 

Workforce Management and Consulting, 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 to discuss ‘‘Human Resources Challenges’’ within the Department 

of Veterans Affairs (VA) Veterans Health Administration (VHA). Our challenges 

cover recruitment and retention programs, improving and streamlining the recruitment process, and other issues related to developing and maintaining a qualified 

and diverse workforce of healthcare professionals. 

As the Nation’s largest integrated healthcare delivery system, VHA’s workforce 

challenges mirror those of the healthcare industry as a whole. VHA experiences 

pressures equal to or greater than other healthcare organizations. VHA performs extensive national workforce planning and annually publishes a Workforce Succession 

Strategic Plan that includes workforce analysis and planning for each Veterans Integrated Service Network (VISN) and national program office. VHA’s Strategic Plan 

addresses current and emerging initiatives in areas including, but not limited to, 

recruitment and retention, mental healthcare, polytrauma, traumatic brain injury, 

and rural health to address workforce efforts. 

VHA’s Strategic Plan identifies mission-critical occupations which are considered 

shortage categories, as well as recruitment and retention initiatives at the local, regional and national levels. For each of the nationally ranked mission critical occupations, VA conducts a thorough historical and projected workforce analysis. Plans are 

established at every level to address turnover, succession planning, developmental 

opportunities, and diversity issues. VHA uses equal employment opportunity comparison data for each of the critical occupations, as well as the workforce nationwide, 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 has presented it to other 

Federal agencies as well as by means of OPM’s ‘‘A Best Practice Leadership Forum 

On Succession Management’’ conference. 

Efforts to Recruit Health Care Professionals 

It is important that the supply of appropriately prepared healthcare workers meet 

the needs of a growing and diverse population. Enrollment in nursing schools needs 

to grow to meet the projected future demand for healthcare providers. 


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More than 100,000 health professional trainees come to VA facilities each year for 

clinical learning experiences. Many of these trainees are near the end of their education or training programs and become a substantial recruitment pool for VA employment as health professionals. The annual VHA Learners’ Perceptions Survey 

shows trainees were twice as likely to consider VA employment after completing 

their VA learning experiences than they were before. This demonstrates many trainees were not aware of VA employment opportunities or the quality of VA’s 

healthcare environment prior to VA training, but became considerably more interested after their VA clinical experiences. 

An informal survey of all VA facilities in 2007 found that 74 percent of the 800 

psychologists hired over the last 3 years received some training in professional psychology through VA. This year, VHA’s Offices of Academic Affiliations (OAA) and 

Patient Care Services significantly expanded VA’s psychology training programs in 

anticipation of the ongoing need for additional VA psychologists. 

The Healthcare Retention and Recruitment Office (HRRO) is distributing a new 

recruitment brochure titled ‘‘From Classroom to Career’’ to VA trainees. The Office 

of Academic Affiliations in VA Central Office emphasizes trainee recruitment to 

education leaders in VA facilities. The VHA leadership has raised the trainee recruitment issue to a higher priority. 

In an effort to initiate proactive strategies to aid in the shortage of clinical faculty, VA launched the VA Nursing Academy (Academy) to address the nationwide 

shortage of nurses. The purpose of the Academy is to expand the number of nursing 

faculty in schools, increase student nursing enrollment by 1,000 students, increase 

the number of students who come to VA for their clinical learning experience, and 

promote innovations in nursing education and clinical practice. Four partnerships 

were established for the 2007—2008 school year. Four additional partnerships will 

be selected each year in 2008 and 2009 for a total of twelve partnerships. 

The VA Travel Nurse Corps is an exciting new program that established a pool 

of registered nurses (RNs) in VA who can be available for temporary, short-term assignments at VA medical centers throughout the country; this program is being piloted at two sites, San Diego and Phoenix. The VA Travel Nurse Corps meets 

nurses’ needs for travel and flexibility while meeting VA medical center needs for 

temporary, high quality nurses. The goals of the program are to maintain high 

standards of patient care quality and safety; reduce the use of outside supplemental 

staffing; improve recruitment of new nurses into the VA system; improve retention 

by decreasing turnover of newly recruited nurses; provide alternatives for experienced nurses who may leave the VA system; and establish a potential pool of RNs 

for national emergency preparedness efforts. The VA Travel Nurse Corps program 

may also serve as a model for an expanded multidisciplinary VA Travel Corps in 

the future. 

Student programs, such as the VA Learning Opportunities Residency (VALOR) 

Program, the Student Career Experience Program (SCEP), and the Hispanic Association of Colleges and Universities (HACU) Internship Program, have helped VA 

meet its workforce succession needs. VALOR is designed to attract academically successful students of baccalaureate nursing programs and pharmacy doctorate programs. VALOR offers a paid internship and gives the honor students the opportunity to develop competencies in their clinical practice in a VA facility under the 

guidance of a preceptor. In response to the success of the VALOR program for 

nurses, VA added a pharmacy component in 2007. SCEP and HACU offer students 

work experience related to their academic field of study. VHA’s goal is to actively 

recruit these students for permanent employment following graduation. VA National 

Database for Interns is a newly designed database developed to track students in 

VA internship/student programs and to create a qualified applicant pool. 

The Graduate Health Administration Training Program (GHATP) provides practical work experience to students and recent graduates of healthcare administration 

masters programs. On an annual basis, 40–45 GHATP residents and fellows are 

competitively selected and, upon successful completion of the programs, are eligible 

for conversion to a permanent position. The Technical Career Field program is designed to fill entry level vacancies in areas like Budget, Finance, Human Resources, 

and Engineering, where shortages are predicted and VA-specific knowledge is critical to success. Recruitment is focused on colleges and universities. Each intern is 

placed with an experienced preceptor in a VHA facility. The program is designed 

to be flexible and responsive to the changing needs of the workforce, as the target 

positions and the number of intern slots are determined based on projected needs. 

Challenges Hiring Health Professional in Rural Areas 

VA recognizes that rural communities face additional healthcare workforce challenges. Many of the access and quality challenges rural patients face begin with a 


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shortage of healthcare providers. VA is working to develop an effective rural workforce strategy to recruit locally for a broad range of health-related professions. 

Experiential training opportunities for young medical students are important investments for creating a veteran- and rural-friendly physician workforce. VA is 

working to integrate rural areas into residency rotations, since evidence shows those 

who serve residencies in rural areas are more likely to practice in rural areas. 

Streamlining the Hiring Process 

Last year, VHA’s Human Resource Committee chartered a workgroup to streamline the recruitment process for Title 5 and Title 38 positions within VHA. The 

workgroup initially analyzed the recruitment process and identified barriers and 

lengthy processes for Registered Nurses. VHA conducted a pilot program in VISN 

4 (Pittsburgh, PA) where the group’s recommendations were put into practice. The 

recommendations were piloted there with the implementation and results of the 

pilot rolled out nationwide using information from this pilot. This spring and summer, VA is offering training in systems redesign nationally at Human Resources 

Cluster meetings. These sessions will focus on new strategies and systems redesign 

elements that can be used to help meet the daily challenges of attracting and retaining critical healthcare professionals. 

VA has direct appointment authority for several Title 38 occupations, including 

physical therapists. We recognize that physical therapists are essential to the rehabilitation of injured veterans, and VHA is in the final stages of working with the 

Office of Human Resources Management to develop a new qualification standard, 

which should be implemented later this year. 

In October 2007, VHA consolidated the Delegated Examining Units from 19 decentralized units to eight centralized units, fully automated offices which process all 

VHA requests for external Title 5 job applicants. The centralization, consolidation 

and automation of this function have helped VHA achieve reductions in the timeframes for announcing Title 5 positions to the general public; qualifying candidates 

and generating certificates of eligible candidates for hiring managers. Metrics have 

been established and tracking implemented to measure the competitive hiring process within VHA. Improvements in timelines for processing are expected to continue 

throughout the year. 

Innovative Retention Strategies 

One retention strategy that has proven very successful for VHA was approved in 

Public Law 108–445 (dated December 3, 2004 and effective January 8, 2006). VHA 

physician and dentist pay consists of three elements: base pay, market pay, and performance pay. P.L. 108–445 improves VA’s ability to recruit and retain the best 

qualified workforce capable of providing high quality care for eligible veterans. VA 

is committed to ensuring 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 similar services. Between the 

time the pay bill went into effect and the end of February 2008, we have increased 

the number of VA physicians by over 1,430 FTE. Also as a component of this legislation, VA has the discretionary ability to set Nurse Executive Pay to ensure we continue to successfully recruit and retain nursing leaders. 

National Recruitment/Media Marketing Strategies 

The VHA Healthcare Retention & Recruitment Office (HRRO) administers national programs to promote employment branding with VHA as the healthcare 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. 

Recent marketing studies for nursing and pharmacy have been the driving force 

for many of our successful campaigns. HRRO works at the national level to promote 

recruitment branding and to provide tools, resources, and other materials to support 

both national branding and local recruiting. The current annual recruitment advertising budget is $1.8 million. Some of the features of this program are: 

• Integration of VHA’s recruitment website search engine 

(www.VACareers.va.gov) with the USA Jobs (www.USAjobs.opm.gov) search engine. This combined resource provides consolidated information on careers in 

VHA, job search capability, and information on Federal employment pay and 

benefits information. This integration was completed in March 2008. 

• Public Service Announcements (PSAs) promote the ‘‘preferred healthcare employer’’ image of VHA. PSAs emphasize the importance and advantage of careers with VA and focus on the personal and professional rewards of such a career. 


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• A comprehensive online advertising strategy where VA positions are promoted 

on commercial employment websites like Career Builder, Healthcareers, and 

others. Advertising on online health information networks expands our reach to 

over 5,000 discrete websites at a cost of just over $500,000 annually. VA’s strategy includes banner advertising directing traffic to the VACareers website for 

employment information and adding keyword searches to Google and Yahoo! to 

elevate VA jobs to the top of the list of search results on these sites. This advertising results in over 100,000 visits to the VA recruitment website each month. 

• Print advertising includes both direct classified advertising and national employment branding. The national program provides ongoing exposure of VA 

messaging to potential employees and promotes VA as a leader in patient care. 

VHA print advertising reaches over 34 million potential candidates. 

• VHA Health Care Recruiters’ Toolkit is a unique virtual community internal to 

VHA. This toolkit is an online management program coordinating national and 

local recruitment efforts for healthcare professionals and serves as a resource 

by providing available recruitment tools, materials, advertisements, and other 

related information at recruiters’ fingertips. 

• VHA’s National Recruitment Advisory Groups represent top mission critical occupations that collaborate on an interdisciplinary approach to address recruitment and retention. 

In Fiscal Year 2007, HRRO developed a comprehensive recruitment marketing 

plan for mental health professionals using some of the strategies mentioned earlier, 

as well as financial recruitment incentives. Funding was dedicated for Mental 

Health Enhancement Initiative Education Debt Reduction Program (EDRP) positions. As of May 1, 2008, awards had been made to 144 participants. The total payout for these participants is over $5,235,000 over a 5-year service period. The average total award is $36,355. 

Financial Incentives for Recruitment and Retention 

Both a recruitment and retention tool, the Employee Incentive Scholarship Program (EISP) pays up to $35,900 for academic healthcare-related degree programs. 

Between 1999 and May 1, 2008, 7,524 VA employees have received scholarship 

awards for academic education programs related to Title 38 and Hybrid Title 38 occupations, and more than 4,200 employees have graduated. Scholarship recipients 

include RNs (93 percent), pharmacists, and many other allied health professionals. 

Focus group market research shows staff education programs offered by VHA are 

considered a major factor in individuals selecting VA as their choice of employer. 

A 5-year analysis of program outcomes demonstrated positive employee retention. 

Less than 1 percent of nurses leave VHA during their service obligation period, from 

one to 3 years after completion of degree. 

The Education Debt Reduction Program (EDRP) provides tax free reimbursement 

of education loans/debt to recently hired Title 38 and Hybrid Title 38 employees. 

EDRP is similar to the Student Loan Repayment Program, under Office of Personnel Management (OPM) regulations. VA has the authority to award up to 

$50,824. Currently, the maximum award amount is capped at $48,000 and is tax 

free. The maximum award amount is usually increased each fiscal year. As of May 

1, 2008, 6,467 healthcare professionals were participating in EDRP. The average 

amount authorized per student, since the inception of EDRP, is $18,394. The average award amount per employee has increased each fiscal year from over $13,500 

in FY 2002 to over $29,000 in FY 2008 as education costs have increased. While 

employees from 34 occupations participate in the program, 75 percent are from 

three mission critical occupations: registered nurses, pharmacists and physicians. 

These figures include the mental health initiative EDRP awards discussed previously. 

Resignation rates of EDRP recipients are significantly less than non-recipients as 

determined in a 2005 study that showed: 

• The resignation rate for nursing EDRP recipients was 14.3 percent while the 

resignation rate for non-EDRP recipients was 28 percent—a 13.7-percent difference. The resignation rate for physician EDRP recipients was 15.9 percent 

while the resignation rate for non-EDRP recipients was 34.8 percent—an 18.9- 

percent difference. The resignation rate for pharmacy EDRP recipients was 13.4 

percent while the resignation rate for non-EDRP recipients was 27.6 percent— 

a 14.2-percent difference. 

A study of the EDRP program retention rates in 2007 showed 75 percent of pharmacists and nurses who received EDRP awards in 2002 were still employed by VA 

at the end of the initial 5-year period of the program’s operation. Among physicians, 


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65 percent were still employed. Although a smaller percentage, it represents a substantial retention level. 

VHA routinely uses hiring and pay incentives established under Title 5 and Title 

38. Financial recruitment incentives, retention incentives (both individual and 

group), special salary rates, relocation incentives and other incentives are routinely 

used and documented in VHA’s Workforce Succession Strategic Plan. Recruitment 

and retention incentives are used to reduce turnover rates and help fill vacancies. 

In Fiscal Year 2007, nearly $24 million in recruitment incentives were provided to 

over 3,150 Title 38 and Title 38 Hybrid employees, while more than $34 million in 

retention incentives were given to 5,300 Title 38 and Title 38 Hybrid employees. 

Employee Entrance and Exit Survey Analysis 

In 2000, VA began using an electronic database to capture survey information 

from employees entering and exiting VA service. The entrance survey is an excellent 

tool for comparing and contrasting reasons the new workforce has come to work for 

VHA and for determining recruitment sources used by candidates (for example, 

newspaper advertisements, employee referrals, online job postings, etc.). The exit 

survey tracks the reasons why staff leaves VHA employment. 

Survey results of 2006 and the first half of 2007 show advancement and development opportunities, benefits, and job stability were the top reasons to work for VA. 

VA’s 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 opportunities elsewhere, and family matters (marriage, pregnancy, etc.). These findings provide valuable insight for developing recruitment marketing messages and establishing programs to improve retention. 

Conclusion 

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. 

I would like to thank the Committee for your interest and support in implementing legislation that allows us to compete in the healthcare market. 

f 

MATERIAL SUBMITTED FOR THE RECORD 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

June 5, 2008 

Honorable James B. Peake, M.D. 

Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Secretary Peake: 

Thank you for the testimony of Joleen Clark, Chief Officer, Workforce Management and Consulting, Veterans Health Administration, at the U.S. House of Representatives Committee on Veterans’ Affairs Subcommittee on Health hearing that 

took place on May 22, 2008 on ‘‘Human Resources Challenges Within the Veterans 

Health Administration.’’ 

Please provide answers to the following questions by July 17, 2008, to Chris Austin, Executive Assistant to the Subcommittee on Health. 

1. In your statement you reference the VHA’s Strategic Plan and that it 

identifies mission-critical occupations which are considered shortage 

categories. 

• Could you tell this Subcommittee what are the top three mission-critical occupations? 

• What initiatives have been undertaken in the past year to help alleviate the 

shortages of these three critical occupations? 

• How successful have the initiatives been? 


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2. Let’s talk about the hiring process. We know that the application process is extremely onerous to a potential employee, not to mention it 

takes months to fill a position. 

• For the mission-critical occupations, what is the average length of time it 

takes to fill a position? 

• What is the number one reason a potential candidate turns down employment with VA? 

• What has VHA done to help expedite the hiring process? 

3. What do you believe is VHA’s number one challenge in filling shortage 

positions? 

4. Regarding the challenges facing VHA with hiring in rural areas. You 

state in your testimony that ‘‘VA is working to integrate rural areas 

into residency rotations, since evidence shows those who serve 

residencies in rural areas are more likely to practice in rural areas.’’ 

• How does that program work and who are you working with to accomplish 

that? 

• Please tell me how far along VHA is with ‘‘working to integrate rural areas 

into residency rotations? 

Additionally, please answer the following questions for Congressman Vic Snyder: 

1. For each category (i.e. Title 38, Title 5 and hybrid), what is the current 

total cost per hire? 

2. What are the existing advertising costs? 

• What are the total advertising costs per hire? 

3. What is the total volume of generated leads by source per month? 

• What is the average hire rate based on that source? 

4. What are the projected staffing requirements (RN nurse positions 

only) considering existing vacancies, losses due to anticipated turnover, and anticipated retirement losses through 2015? 

5. What is the current cycle timeframe from a commitment to hire an application and to actual hire date? 

6. Would you please rank in descending order the percentage of closing 

of each source (i.e., walk-ins, Internet, phone inquiries, billboard, 

radio, etc.)? 

Thank you again for taking the time to answer these questions. The Committee 

looks forward to receiving your answers by July 17, 2008. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 

Questions for the Record 

The Honorable Michael H. Michaud, Chairman 

Subcommittee on Health 

House Committee on Veterans’ Affairs 

May 22, 2008 

Human Resources Challenges within the Veterans Health Administration 

Question 1(a): In your statement you reference VHA’s Strategic Plan and that 

it identifies mission-critical occupations which are considered shortage categories. 

Could you tell this Subcommittee what are the top three mission-critical occupations? 

Response: The top three mission-critical occupations within the Veterans Health 

Administration (VHA) are registered nurses, physicians, and pharmacists. 

Question 1(b): What initiatives have been undertaken in the past year to help 

alleviate the shortages of these three critical occupations? 

Response: The Department of Veterans Affairs (VA) has undertaken several initiatives to help reduce the shortages of mission-critical occupations: 

• Offering student loan repayment 

• Tuition support/scholarship programs 


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• Special salary rates may be authorized for hybrid, title 38 and title 5 positions 

when: 

• hiring or retention efforts are likely to become significantly handicapped due 

to factors such as higher rates of pay being offered by private sector employers 

• the duty station is in a remote location 

• the nature of the work or working condition is unfavorable (i.e., exposure to 

occupational or health hazards) 

• Retention/Recruitment Incentives (recruitment and retention payments provide 

monetary incentives for individuals to accept employment or remain employed 

in Federal Service) and 

• Developmental/promotional opportunities 

Question 1(c): How successful have the initiatives been? 

Response: The initiatives have been successful in reducing turnover rates in the 

top three mission-critical occupations. Since 2002, these initiatives have been successful in reducing turnover rates in the top three mission-critical occupations. VA 

has also brought on board more employees in these occupations in fiscal year (FY) 

2007 than any time in the last 10 years and increased the end-of-year onboard head 

count by an additional 968 physicians (6.3-percent increase), 2,449 registered nurses 

(6.2-percent increase), and 238 pharmacists (4.8-percent increase). This is more than 

double the increase seen in most of the previous 10 years for these occupations. VA 

expects to see a larger increase in each of these occupations this year. VA is projecting 7.2 percent, 8.7 percent, and 6.2 percent increases for the end of FY 2008. 

This means that our recruiting efforts have been phenomenal and our human resources shops have been working incredibly hard to bring on the additional physicians, nurses, and pharmacists VA needs to fulfill the mission. 

Question 2(a): Let’s talk about the hiring process. We know that the application 

process is extremely onerous to a potential employee, not to mention it takes months 

to fill a position. For the mission-critical occupations, what is the average length of 

time it takes to fill a position? 

Response: After identifying a candidate, the average length of time to fill a mission-critical occupation is approximately 10 days (if being hired as temporary) to 180 

days. There are a number of steps in the hiring process that must be completed before a candidate can be appointed on a permanent basis. VA performs reference 

checks and credentials are verified through the necessary sources. Title 38 and hybrid title 38 candidates must be evaluated by a Professional Standards Board, and 

compensation panels need to recommend pay for physicians and dentists. Additionally, preemployment physicals have to be performed and candidates have to give 

proper notice to their previous employer. 

Question 2(b): What is the number one reason a potential candidate turns down 

employment with VA? 

Response: Non-competitive salary with the local market is the number one reason why a potential candidate turns down employment with VA. 

Question 2(c): What has VHA done to help expedite the hiring process? 

Response: VHA has several initiatives underway to shorten the hiring and review process. The initiatives involve: policy revisions, software development, retooling and focusing on streamlining the hiring process. VHA is looking at credentialing 

timelines and background investigations. In addition, facilities are undertaking a 

systems redesign process that will focus on improving the staffing process. 

Question 3: What do you believe is VHA’s number one challenge in filling shortage positions? 

Response: VHA’s number one challenge in filling shortage positions is the limited 

supply of medical professions, particularly in specialized areas. Private and Federal 

sectors are competing for hard-to-fill positions with a limited pool of professionals 

in certain specialties. This makes recruiting and retaining medical professionals in 

these core professions a challenge. 

Question 4(a): Regarding the challenges facing VHA with hiring in rural areas. 

You state in your testimony that ‘‘VA is working to integrate rural areas into residency rotations, since evidence shows those who serve residencies in rural areas are 

more likely to practice in rural areas.’’ How does that program work and who are 

you working with to accomplish that? 

Response: The VHA Office of Academic Affiliations (OAA) oversees an extensive 

portfolio of training programs around the country, encompassing over 100,000 trainees per year having clinical experiences at VA sites. In recent years, OAA has encouraged and incentivized training in rural areas. Over 400 paid trainees (including 

125 physician residents) and over 4,000 unpaid trainees participate in training at 


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rural sites. Training programs exist at 22 out of 31 medical centers that support 

rural or highly rural markets. 

Through an initiative known as the graduate medical education (GME) enhancement program, OAA has funded medical training experiences in more remote VA 

sites. One specific component, New Affiliations and New Sites of Care, encourages 

trainee rotations at community based outpatient clinics (CBOC), as well as at other 

new sites of care. To date, OAA has funded over 80 new physician resident positions 

in 21 sites through this program; over 13 of these positions have been allocated to 

officially designated rural sites. More than 10 additional positions have been awarded to rural locations not officially designated as such (Boise, Idaho; Northampton, 

Massachusetts; and the CBOC in Pine Bluff, Arkansas). 

VHA also recognizes the need for more infrastructure support at rural sites in 

order to ensure that residents have an excellent educational experience—without 

which they are unlikely to view rural practice in a favorable light. Thus, OAA and 

the Office of Rural Health are currently discussing the feasibility of partnering in 

order to further expand OAA’s GME enhancement initiative to include more resource support for rural and highly rural hospitals and CBOCs as training locations. 

Question 4(b): Please tell me how far along VHA is with ‘‘working to integrate 

rural areas into residency rotations.’’ 

Response: VHA’s efforts to integrate rural sites into training programs are still 

evolving. VA’s care initiatives, including new affiliations and new sites, are only in 

the second year of implementation. The Office of Rural Health is in the process of 

collaboration with OAA to pursue these initiatives. 

Questions for the Record 

Hon. Vic Snyder 

Question 1: For each category (i.e. Title 38, Title 5, and hybrid), what is the current total cost per hire? 

Response: VHA does not track the total cost per hire due to the complexities of 

allocating direct and indirect costs of multiple staffers involved in the hiring process. 

Question 2: What are the existing advertising costs? What are the total advertising costs per hire? 

Response: The Healthcare Recruitment and Retention Office (HRRO), a part of 

the Workforce Management Office, spends approximately $2.5 million per year on 

print advertising, collateral materials (brochures, flyers, and promotional items), 

web design and promotion and by participating in career fairs, conferences, trade 

shows and other events annually. HRRO also provides local and national VA recruiters with valuable tools through its toolkit of developed ads, banners, and event 

displays to promote consistent branding in support of recruitment efforts. 

VA does not track the total advertising cost per hire due to complexities of properly allocating funds VHA may have expended at the local and national level to fill 

a position. 

Question 3(a): What is the total volume of generated leads by source per month? 

Response: VA does not collect data that provides the total volume of generated 

leads by source per month or data that provides the average hire rate based on that 

source; however, based on entrance surveys, we know that the number one method 

applicants find out about open positions is through the Internet—employee referral 

is the second source. 

Question 3(b): What is the average hire rate based on that source? 

Response: VA does not track the data that gives the exact breakdown as multiple 

sources could have influenced a new employee to accept a position within VA. 

Question 4: What are the projected staffing requirements (RN nurse positions 

only) considering existing vacancies, losses due to anticipated turnover, and anticipated retirement losses through 2015? 

Response: Currently, there are an estimated 1,700 vacancies (which equate to 

10.7 percent vacancy rate) for registered nurses. The turnover rate for this fiscal 

year 2008 has been approximately 5 percent. Projections for future hires through 

2013 are projected at an increase of 19 percent from approximately 42,000 to 50,000. 

There is projected to be a loss of 7,600 registered nurses due to retirement by the 

year 2013 or approximately 15 percent over that same time period. 

Question 5: What is the current cycle timeframe from a commitment to hire an 

applicant and to actual hire date? 

Response: Generally, it takes approximately 30 to 180 days from a commitment 

to hire an applicant to the actual hire date. Many facilities are moving closer to the 

30-day timeframe as a result of ongoing initiatives. 


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Question 6: Would you please rank in descending order the percentage of closing 

of each source (i.e. walk-ins, Internet, phone inquiries, billboard, radio, etc.)? 

Response: Based on the 2007 Entrance Survey Results, the following sources in 

descending order represent how a new hire heard about job opportunities within VA. 

a. (33.25 percent) VA Internet Job Opportunities Site—www.vacareers.va.gov 

b. (32.38 percent) VA Employee Referrals 

c. (15.34 percent) Other (i.e. friend, veteran, colleague, conference) 

d. (7.92 percent) College or University 

e. (5.71 percent) Newspapers & Magazines 

f. (4.58 percent) Office of Personnel Management Job Notice 

g. (0.68 percent) Career Counselor 

h. (0.13 percent) No Response 

Æ 


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