VA Health Care: Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists
Published: 2007-12-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Certified registered nurse anesthetists (CRNA), registered nurses who have completed a master's degree program in nurse anesthesia, provide the majority of anesthesia care veterans receive in VA medical facilities. While the demand for CRNAs is anticipated to increase, many CRNAs employed by VA--VA CRNAs--are nearing retirement eligibility age. Concerns have been raised about the challenges VA may face in maintaining its VA CRNA workforce. GAO (1) identified VA CRNA workforce challenges that VA medical facilities may experience related to VA CRNAs, (2) identified the key mechanisms that VA medical facilities can use to recruit and retain VA CRNAs, and (3) determined the extent to which facilities use the key mechanisms. To identify VA CRNA workforce challenges, GAO analyzed Web-based surveys it sent to VA chief anesthesiologists, VA human resources officers, and VA CRNAs, with survey response rates of 92, 85, and 76 percent, respectively. GAO also identified the key mechanisms VA medical facilities can use to recruit and retain VA CRNAs and the extent that these mechanisms are used.
section_title: What GAO Found
paragraphs: Department of Veterans Affairs (VA) medical facilities have challenges in recruiting and retaining VA CRNAs for their workforce. About three-fourths of all VA medical facility chief anesthesiologists responding to GAO's survey reported that they had difficulty recruiting VA CRNAs. The challenge recruiting VA CRNAs has made it difficult to fill existing VA CRNA vacancies at VA medical facilities. Overall, 54 percent of VA medical facility chief anesthesiologists reported temporarily closing some operating rooms and 72 percent reported delaying some elective surgeries. VA's retention challenge comes from a projected substantial attrition rate. Based on the results of its survey, GAO projects that 26 percent of VA's CRNAs will either retire from or leave VA in the next 5 years. VA medical facility officials reported in GAO's survey that the recruitment and retention challenges are caused primarily by the low level of VA CRNA salaries when compared with CRNA salaries in local market areas. VA has three key mechanisms its medical facilities can use to recruit and retain VA CRNAs. VA medical facilities can give bonuses to VA CRNAs--recruitment, relocation, and retention bonuses. In addition, VA has education payment programs that provide funding to cover CRNA education costs. Finally, medical facilities can also use VA's locality pay system (LPS) to determine whether to adjust VA CRNA salaries to help the facilities remain competitive with CRNA salaries in local market areas. Each of the three key recruitment and retention mechanisms--bonuses, education payment programs, and VA's LPS--are used by some VA medical facilities. GAO found that in fiscal years 2005 or 2006, just over one-third of VA medical facilities that hired VA CRNAs gave recruitment bonuses. For VA medical facilities that have VA CRNAs, less than one-third gave retention bonuses in fiscal years 2005 or 2006. In addition, all VA CRNAs that applied for funds to attend a CRNA school or to offset their educational debt and were eligible received these funds in fiscal years 2005 and 2006. GAO also found that more than half of VA medical facilities used VA's LPS to determine whether to adjust VA CRNA salaries in 2005 and in 2006. However, in the eight VA medical facilities visited, GAO found that although the facilities used VA's LPS, the majority of them did not fully follow VA's LPS policy correctly in either 2005 or 2006. Officials at these facilities did not always know or were not aware of certain aspects of the LPS policy, and VA has not provided training on the LPS to VA medical facility officials since the policy was changed in 2001. As a result, VA medical facility officials have not received LPS training that reflects VA's current LPS policy, and accordingly, cannot ensure that VA CRNA salaries have been adjusted as needed to be competitive. Although VA is in the process of developing a Web-based training course for the LPS, the department has not established a time frame for finalizing the development and implementation of this training course.

section_title: Letter
paragraphs: Certified registered nurse anesthetists (CRNA) provide the majority of  anesthesia care veterans receive in medical facilities operated by the  Department of Veterans Affairs (VA). CRNAs are registered nurses who  have completed a 2 to 3 year master’s degree program in nurse anesthesia  and who typically provide anesthesia care in health care settings with  anesthesiologists and surgeons. There are approximately 500 VA-employed  CRNAs (VA CRNA) who provide anesthesia care to veterans in VA medical  facilities. The demand for CRNAs in VA medical facilities has continued to  increase because CRNAs are no longer used only in the operating room,  but are used in other areas of a medical facility, such as administering  anesthesia to patients who are undergoing cardiac catheterization and  providing airway management to patients during cardiac emergencies.
While the demand for CRNAs is anticipated to increase, many VA CRNAs  are nearing retirement eligibility age. According to VA officials, more than  half of VA CRNAs are over the age of 51, and the average VA CRNA is   7 years closer to retirement eligibility than the average CRNA nationally.  Because CRNAs provide the majority of anesthesia services in VA medical  facilities and facility officials have reported problems with recruiting and  retaining VA CRNAs, concerns have been raised about the challenges VA  may face in maintaining its VA CRNA workforce, particularly in some local  market areas where the labor market for CRNAs can be highly  competitive.
You asked that we review VA’s efforts to recruit and retain VA CRNAs. In  this report, we (1) identify workforce challenges that VA medical facilities  may experience related to VA CRNAs, (2) identify the key mechanisms  that VA medical facilities can use to recruit and retain VA CRNAs, and   (3) determine the extent to which VA medical facilities use the key  mechanisms to recruit and retain VA CRNAs.
To identify workforce challenges VA medical facilities may experience  related to VA CRNAs, we analyzed data obtained from three of our Web- based surveys. The first survey, administered to VA CRNAs, obtained a  response rate of 76 percent and allowed us to determine whether these VA  CRNAs plan to retire or leave VA’s health care system within the next   5 years. The second survey was administered to VA medical facilities’ chief  anesthesiologists and obtained a 92 percent response rate, and the third  survey was administered to VA human resources (HR) officers and  obtained an 85 percent response rate. We used the second and third  surveys to identify the issues VA medical facilities face when recruiting  and retaining VA CRNAs. We also analyzed data on VA CRNA vacancies— the number of unfilled VA CRNA positions at VA medical facilities— obtained from VA headquarters. These data were from 2005, the most  recent year for which vacancy data were available. Additionally, we  obtained data on VA CRNAs’ salaries for 2005, 2006, and 2007 and  compared these to salary data we obtained from the American Association  of Nurse Anesthetists (AANA), a professional organization for CRNAs, to  determine whether VA medical facilities’ salaries for VA CRNAs are  competitive with CRNA salaries in local market areas. We interviewed a  representative from Kaiser Permanente, a large health care plan that  primarily uses CRNAs to deliver anesthesia services, to identify what steps  this health plan takes to ensure it has a sufficient number of CRNAs and to  determine the indicators this plan uses to identify a CRNA shortage or  potential future CRNA shortage.
To ensure the reliability of the data we used, we interviewed VA and  AANA officials about the quality checks and edits they performed on their  data. In addition, we assessed the data obtained from our three Web-based  surveys by performing a systematic review of the returned questionnaires.
On the basis of our assessment we determined these data were adequate  for our purposes.
To determine the key mechanisms that VA medical facilities use to recruit  and retain VA CRNAs, we reviewed VA’s policies and directives related to  VA CRNAs and obtained reports on VA CRNAs’ salaries, bonuses,  education programs, and qualification standards. We interviewed officials  at VA headquarters and selected VA medical facilities. To determine the  extent to which VA medical facilities use key mechanisms to recruit and  retain VA CRNAs, we visited eight VA medical facilities located in Denver,  Colorado; Houston, Texas; Minneapolis, Minnesota; New York, New York;  Portland, Oregon; Seattle, Washington; Tampa, Florida; and Togus, Maine.  We selected these facilities because they are geographically dispersed  across the country and employ VA CRNAs. At each VA medical facility we  visited, we interviewed chief anesthesiologists, VA CRNAs, HR officers,  and other facility officials and asked them about their efforts to recruit and  retain VA CRNAs. We also analyzed data obtained from our three Web- based surveys to determine the extent to which VA medical facilities use  the key mechanisms to recruit and retain VA CRNAs. For a complete  description of our scope and methodology, see appendix I. The results of  our surveys are provided in appendixes II, III, and IV. We conducted our  work from June 2006 through October 2007 in accordance with generally  accepted government auditing standards.
subsections: section_title: Background
paragraphs: Anesthesia services are provided by anesthesia practitioners—typically  anesthesiologists and CRNAs. Anesthesiologists are physicians who have  completed medical school and typically a 4-year anesthesiology residency.  Both anesthesiologists and CRNAs administer anesthesia for all types of  surgical procedures, working either as single providers or together.  Anesthesia services can be provided by anesthesiologists alone, by  anesthesiologists working with CRNAs, by CRNAs alone, or by  anesthesiologist assistants (AA), working under the supervision of an  anesthesiologist. AAs are graduates of a medical-school-based AA  education program. (See app. V for the education and training  requirements for anesthesiologists, CRNAs, and AAs.)
The nurse anesthetist profession has made efforts to meet the demand for  CRNA services in the public and private health care sectors. The  profession has increased the number of accredited CRNA training  programs, and as a result the number of CRNA graduates has increased— over 2,000 graduates in 2007, 57 percent more than in the year 2000. The  growth in the demand for CRNAs is expected to continue.
A joint Department of Defense (DOD)/VA program in nurse anesthesia  education was established in 2004 at Fort Sam Houston in San Antonio,  Texas. This 30-month program, run by the United States Army, educates  military personnel and VA registered nurses to become CRNAs. New VA  CRNAs who complete this program have a 3-year service obligation to VA  upon graduation.
When hiring VA CRNAs, VA places them in one of five pay grades, based  on the CRNA’s education and experience. VA’s qualification standards for  VA CRNAs establish the five grades with grade I being the lowest. The  grades ultimately determine the salary for each VA CRNA working in a VA  medical facility. Within each grade, there are a number of steps—generally  12—that represent progressive increments of a 3 percent increase in salary  within the grade. For example, the salary of a VA CRNA that is at grade II,  step 2, is 3 percent more than a VA CRNA’s salary at grade II, step 1. VA  CRNA qualification standards indicate that new graduate VA CRNAs  usually begin at grade I, receiving a lower salary because of the lack of  work experience, whereas experienced VA CRNAs might start at grade II  or III receiving a higher salary. VA medical facilities’ salaries for a VA  CRNA at a grade I, step 1, range from a low of $37,432 to a high of $104,575  in market areas where salaries are higher.
VA CRNAs typically work under the medical direction of a chief  anesthesiologist, who is responsible for supervising anesthesia clinical  staff, such as other anesthesiologists and nurse anesthetists. Chief  anesthesiologists are responsible for the quality and safety of anesthesia  services provided in the medical facility. VA CRNA benefits and other  personnel issues, such as hiring and setting base salaries, are managed by  VA medical facilities’ HR officers. HR officers are also responsible for  issues related to compensation, employee and labor relations, recruitment,  and performance management.
VA medical facilities have clinical staff that are trained to provide different  types of health care services. In many cases, the ability to provide health  care services to veterans is dependent on the availability of numerous  types of clinical staff that work in concert with one another to provide  these services. If one of these types of staff is not available, the health care  service may be delayed or not provided. For example, even though a  CRNA is available to provide anesthesia services, if other personnel, such  as operating room nurses or nurses that staff the post-anesthesia recovery  unit, are not available, the surgical procedure may be delayed or cancelled.  Likewise, if a CRNA, or other professional anesthesia staff, are not  available, the surgical procedure may have to be delayed or cancelled.
section_title: VA Medical Facilities Have VA CRNA Recruitment and Retention Challenges Partly Because of Noncompetitive Salaries
paragraphs: VA medical facilities have challenges recruiting and retaining VA CRNAs.  Most surveyed officials reported that they had difficulty recruiting VA  CRNAs at their facilities. The challenge recruiting VA CRNAs affects the  ability of VA officials to reduce existing VA CRNA vacancy rates—the  number of unfilled VA CRNA positions—at their medical facilities. These  rates vary across VA, with 26 medical facilities having vacancy rates of   25 percent or more and 15 of them having vacancy rates of 40 percent or  more. Overall, 54 percent of the chief anesthesiologists responding to our  survey reported temporarily closing some operating rooms and 72 percent  reported delaying some elective surgeries because of VA CRNA vacancies  in fiscal year 2006. On the basis of our survey results, in addition to their  current recruiting challenges, VA medical facilities will likely face a  challenge retaining VA CRNAs in the next 5 years due to the number of VA  CRNAs projected to either retire from or leave VA. VA medical facility  officials reported in our survey that the recruitment and retention  challenges are caused primarily by the low level of VA CRNA salaries  when compared with CRNA salaries in local market areas.
subsections: section_title: VA Officials Report Challenges Recruiting CRNAs, and Projected VA CRNA Attrition Will Create a Retention Challenge in the Next 5 Years
paragraphs: Our survey results indicate that VA medical facilities have a challenge  recruiting VA CRNAs. Of all VA medical facility chief anesthesiologists that  responded to our survey, 74 percent reported that they had difficulty  recruiting CRNAs in fiscal years 2005 and 2006. The recruiting challenges  also affect VA medical facility officials’ ability to reduce existing VA CRNA  vacancy rates at their medical facilities. Additionally, VA medical facility  officials responding to our survey reported that it takes VA facilities a long  time—on average about 15 months—to fill a VA CRNA vacancy from the  time facility management approval is granted to fill the position until the  time the VA CRNA actually begins providing services at the facility. In  particular, VA chief anesthesiologists at 11 medical facilities reported that  their facilities took 2 years or more on average to fill a VA CRNA vacancy.  In our survey, the shortest time taken to fill a vacancy as reported by the  chief anesthesiologists was 2 months, and the longest was 60 months.
The challenge of recruiting CRNAs limits the ability of VA officials to  reduce existing vacancy rates at their medical facilities. VA’s fiscal year  2005 vacancy data show VA had about a 13 percent VA CRNA vacancy  rate systemwide, or 70 unfilled VA CRNA positions at 43 medical facilities.  These rates vary across VA, with 26 medical facilities having vacancy rates  of 25 percent or more and 15 of them having vacancy rates of 40 percent or  more in fiscal year 2005. According to the director of Kaiser Permanente’s  school of anesthesia for nurse anesthetists, a vacancy rate of 40 percent or  higher is considered indicative of a staffing problem. Like VA’s vacancy  data, our survey also suggests that VA CRNA vacancies are common  across VA medical facilities. Of the chief anesthesiologists responding to  our survey, 54 percent reported that they had VA CRNA vacancies at their  VA medical facility, with the number of VA CRNA vacancies ranging from  one to six.
According to our survey, VA CRNA vacancies have impacted the delivery  of services at VA medical facilities. For example, 54 percent of the VA  chief anesthesiologists with VA CRNA vacancies reported that they  temporarily closed operating rooms, 72 percent delayed elective surgeries,  and 68 percent increased the use of overtime for VA CRNAs, as a result of  VA CRNA vacancies in fiscal year 2006. Moreover, 44 percent of chief  anesthesiologists that had VA CRNA vacancies reported that contract  CRNAs were used. In addition, almost one-third of the chief  anesthesiologists whose vacancies were filled reported that they still had a  shortage of VA CRNAs. See table 1 for the types of effects that VA CRNA  vacancies have had on the delivery of services, as reported by chief  anesthesiologists who reported VA CRNA vacancies.
According to some VA chief anesthesiologists who responded to our  survey, the use of contract CRNAs has increased over the last 3 years. In  fiscal years 2005 and 2006, about 30 percent of VA medical facility chief  anesthesiologists who responded to our survey reported using contract  CRNAs to supplement their anesthesia workforce. See table 2 for the  reasons cited by chief anesthesiologists for using contract CRNAs. These  chief anesthesiologists reported on our survey that they used an average of  less than one full-time contract CRNA in both fiscal years 2005 and 2006.  According to our survey, the chief anesthesiologists who reported data for  both contract hours and contract costs reported a median hourly CRNA  contract cost of $112 in fiscal year 2005 and $114 in fiscal year 2006. This  compares to an hourly cost for a full-time VA CRNA of $82 in fiscal year  2005 and $84 in fiscal year 2006 for a VA CRNA earning the maximum  statutory salary.
In addition to the current challenges of recruiting CRNAs, VA medical  facilities are also likely to face another workforce challenge in the future.  Specifically, in the next 5 years VA medical facilities will likely have  difficulty retaining VA CRNAs in their workforce and this trend could  increase the number of VA CRNA vacancies across VA. On the basis of VA  CRNA responses to our survey, we project a VA CRNA attrition rate of   26 percent across VA in the next 5 years—that is, 26 percent of VA CRNAs  either plan to retire or leave VA’s health care system within the next   5 years. Overall, 93 VA CRNAs at 53 of VA’s 120 medical facilities that  employ VA CRNAs reported that they plan to retire or leave VA’s health  care system. While the overall projected attrition rate across VA, on the  basis of our survey results, is likely to be 26 percent, this rate will vary by  medical facility. In 27 VA medical facilities, we project that the attrition  rate is likely to be 50 percent or higher. According to the director of Kaiser  Permanente’s school of anesthesia for nurse anesthetists, an attrition rate  of 50 percent or higher is considered indicative of a future staffing  problem.
section_title: According to VA Officials and VA CRNAs, Difficulty Recruiting and Retaining VA CRNAs is Due to Noncompetitive VA CRNA Salaries
paragraphs: Our surveys of VA medical facility chief anesthesiologists and HR officers  indicate that medical facilities have trouble recruiting and will have  trouble retaining VA CRNAs because salaries for VA CRNAs are low  compared to CRNA salaries in local market areas. Of the 69 chief  anesthesiologists who reported having difficulty recruiting VA CRNAs  during fiscal years 2005 and 2006, about 60 of them attributed this  difficulty primarily to the fact that salaries for VA CRNAs at their medical  facilities were not competitive with CRNA salaries in local market areas.  Additionally, of the 46 chief anesthesiologists who reported having  difficulty retaining VA CRNAs during fiscal years 2005 and 2006, 36 of  them attributed this primarily to the fact that salaries for experienced VA  CRNAs at their medical facilities were not competitive with CRNA  salaries in local market areas. Other reasons most frequently cited by the  chief anesthesiologists were indirectly associated with the level of VA  CRNA salaries.
Of the chief anesthesiologists surveyed, 72 percent (67) of chief  anesthesiologists reported that VA CRNA starting salaries for new  graduates at their facility were lower than local market area salaries in  fiscal year 2005, and 69 percent (64) of chiefs reported this in fiscal year  2006. In fiscal years 2005 and 2006, 79 percent (73) of chief  anesthesiologists estimated that salaries for experienced VA CRNAs at  their medical facility were lower than local market area CRNA salaries.
Furthermore, about 40 percent of chief anesthesiologists also reported  that salaries for both new graduate and experienced VA CRNAs at their  facility were $10,000 to $30,000 lower than CRNAs salaries in local market  areas during fiscal years 2005 and 2006. See table 3 for the differences in  VA CRNA salaries and CRNA salaries in local market areas in fiscal years  2005 and 2006, as reported by VA chief anesthesiologists.
Although the majority—about 79 percent—of VA medical facility chief  anesthesiologists reported that VA CRNA salaries are not competitive with  local market CRNA salaries, less than half of VA medical facility HR  officers who responded to our survey concurred. Our survey results for  new graduates and experienced VA CRNAs showed that in fiscal years  2005 and 2006 about 45 percent of HR officers reported that their facilities’  starting salaries for new graduate VA CRNAs were low when compared  with CRNA salaries in local market areas. In addition, about 47 percent  of HR officers reported that salaries for experienced VA CRNAs were low  when compared with CRNA salaries in local market areas in fiscal years  2005 and 2006. Further, our survey asked HR officers to report how much  lower VA salaries were than local market area salaries for new graduate  and experienced VA CRNAs. Our survey results showed that 17 percent of  HR officers reported that salaries for new graduate VA CRNAs were  $10,001 to $30,000 lower than CRNAs’ salaries in local market areas in  fiscal years 2005 and 2006. Also, about 19 percent of HR officers reported  that salaries for experienced VA CRNAs were $10,001 to $30,000 lower  than CRNAs’ salaries in local market areas in both fiscal years.
Furthermore, of the VA CRNAs who responded to our survey, 69 percent  (250) of VA CRNAs reported that higher starting salaries for new graduate  CRNAs would strengthen VA’s recruitment efforts. When VA CRNAs who  are considering retirement were asked what would make them postpone  retirement, 91 percent (94) reported that higher salaries would delay their  retirement from a VA medical facility. In addition, when VA CRNAs who  are not eligible to retire in the next 5 years were asked what would keep a  VA CRNA from leaving VA, 82 percent (119) of VA CRNAs reported that a  higher salary would keep them working at VA.
A VA headquarters official acknowledged that some medical facilities  currently face recruitment challenges related to VA CRNA salaries. This  official stated that according to anecdotal reports, there are CRNA  recruiting challenges in some local market areas, while in other market  areas there are no problems with recruitment. To address this problem, VA  CRNAs and the director of VA’s anesthesia services told us they are  revising VA CRNA qualification standards, which will have the effect of  increasing starting salaries for new graduate VA CRNAs from grade I to  grade II. However, this revision to VA CRNA qualification standards— increase in grade and resulting starting salary—would be unlikely to make  most VA CRNA starting salaries competitive with local market area CRNA  starting salaries. We compared VA CRNA 2007 salary schedules to  projected AANA 2007 salary data to determine whether VA CRNA salaries  would be competitive with local market area CRNA salaries if salaries for  new graduate VA CRNAs were changed from grade I to grade II. Our  analysis showed that this revision to VA CRNA qualification standards will  not make most VA CRNA starting salaries competitive with local market  area starting CRNA salaries. Specifically, 75 of 120 VA medical facilities  that employ VA CRNAs would have VA CRNA starting salaries below local  market area CRNA salaries by $20,000 or more.
Similar challenges exist related to the retention of VA CRNAs. More than  half of all VA CRNAs earned the maximum statutory salary cap for a VA  CRNA in 2006, which was $133,900. However, at 107 of VA’s 120 medical  facilities that employ VA CRNAs this maximum statutory salary cap is at  least $20,000 lower than CRNA salaries in local market areas, based on our  analysis comparing AANA salary data for CRNAs to VA’s maximum  statutory salary cap of $133,900. According to VA officials, VA has  proposed legislation to increase the maximum statutory salary cap. The  proposal would increase the maximum statutory salary cap for VA CRNAs  by about $9,000. Our analysis comparing AANA salary data for CRNAs to  VA’s CRNA maximum statutory salary cap indicated that increasing the VA  CRNA maximum statutory salary cap by about $9,000 will not, at a  majority of VA medical facilities, make VA CRNA salaries competitive with  CRNA salaries in local market areas. Specifically, we found that after the  proposed change, 70 of the 120 VA medical facilities’ VA CRNA salaries  would still be $20,000 or more below the local market area CRNA  salaries.
section_title: VA Can Offer Bonuses, Pay Education Costs, and Adjust Salaries to Recruit and Retain VA CRNAs
paragraphs: VA has three key mechanisms its medical facilities can use to recruit and  retain VA CRNAs. VA medical facilities can award recruitment, relocation,  and retention bonuses of up to 25 percent of a VA CRNA’s salary,  according to VA’s policy. Additionally, VA has two education payment  programs medical facilities may use to help recruit and retain VA CRNAs.  One program provides funding to registered nurses for training to become  a CRNA, and the other provides funding to offset educational debt  incurred by VA CRNAs. Finally, medical facilities can use VA’s LPS to  determine whether to adjust VA CRNA salaries to help the facilities remain  competitive with CRNA salaries in local market areas.
subsections: section_title: VA Medical Facilities Can Use Bonuses to Recruit and Retain VA CRNAs
paragraphs: VA medical facilities can use two types of bonuses—recruitment and  relocation—to recruit VA CRNAs, and another type of bonus—retention— to retain VA CRNAs. Recruitment, relocation, and retention bonuses can  be used to recruit and retain employees in positions that are difficult to  fill, such as VA CRNAs. VA’s policy allows medical facility officials to  approve bonuses up to 25 percent of VA CRNAs’ salaries for each year the  VA CRNA agrees to work for the VA medical facility. Before approving a  bonus, medical facility officials are required to document that certain  criteria have been met, such as whether the facility is having difficulty  recruiting and retaining VA CRNAs, whether the facility’s VA CRNA  salaries are competitive with CRNA salaries in local market areas, or  whether the facility has a high VA CRNA turnover rate. VA medical  facilities may terminate an agreement to pay a recruitment, relocation, or  retention bonus if this payment does not meet the needs of VA, such as a  lack of medical facility funds. Medical facility directors have discretion to  determine whether to pay a bonus to VA CRNAs.
To receive a recruitment bonus, a VA CRNA must agree to work a  minimum of 6 months and the bonus may be given for a maximum service  period of 4 years. There is a great deal of flexibility in paying out this  bonus, according to VA officials. Facility officials can choose to pay all or  part of the bonus up front or split the bonus over any number of pay  periods. VA medical facilities have authority to use a recruitment bonus if  they are likely to have difficulty recruiting VA CRNAs.
VA CRNAs may receive a relocation bonus to entice them to relocate to  the area where the VA medical facility is located. To receive this bonus, a  VA CRNA must agree to work a minimum of 6 months. Relocation bonuses  are given to CRNAs who must change their job sites and physically  relocate to a different geographic area.
A retention bonus may be given to a VA CRNA for an unlimited service  period and is paid out after the service period is completed if paid on any  basis other than biweekly. VA medical facilities may give a retention bonus  if a special need exists for the VA CRNA’s services and it is likely that the  VA CRNA will resign without the bonus. VA CRNAs who are receiving a  recruitment or relocation bonus are not eligible for a retention bonus  while receiving either of the other two types of bonuses, according to a VA  HR official.
section_title: Two VA Education Payment Programs Allow Medical Facilities to Provide Funding to Cover CRNA Education Costs to Recruit and Retain VA CRNAs
paragraphs: Medical facilities also have two VA education payment programs to aid in  recruiting and retaining VA CRNAs—VA’s Employee Incentive Scholarship  Program (EISP) and VA’s Education Debt Reduction Program (EDRP).  VA’s Healthcare Retention and Recruitment Office (HRRO) manages these  two programs. VA’s EISP was established in March 2000 and is a  scholarship program for VA registered nurses who attend CRNA training  programs. These registered nurses are eligible for an EISP scholarship  after a minimum of 1 year of continuous VA employment. VA’s student  CRNAs can use EISP funding to pay for the cost of their tuition, books,  and for other related educational expenses, such as registration and fees.  Additionally, EISP covers half of the salary of a registered nurse to replace  the CRNA student and the other half is paid by the VA medical facility  where the student will work once the CRNA training program is  completed. VA CRNA students may use EISP funds to attend the joint  DOD/VA nurse anesthesia training program. In fiscal year 2006, the lifetime  maximum amount of a scholarship that could be paid to a VA CRNA  through EISP was $35,024, and the VA CRNA then had a service obligation  to VA for 3 years.
VA’s EDRP, a student loan repayment program established in May 2002, is  available to newly hired clinicians, such as VA CRNAs, and is used as a  recruitment tool by VA medical facilities. In fiscal year 2006, the maximum  amount that could be paid to a VA CRNA for EDRP was $38,000 divided  into annual payments over a 5-year period.
The distribution of funds for both EISP and EDRP varies by medical  facility and is contingent upon the availability of VA funds. Applicants  must be recommended by the medical facility director and approved by  HRRO. VA medical facility selection criteria for both EISP and EDRP  include an individual’s career goals, work performance, workforce needs  of VA, and a recommendation from an immediate supervisor.
section_title: Medical Facilities Can Adjust VA CRNA Salaries Using VA’s LPS
paragraphs: While VA CRNA grades, which establish VA CRNA salaries, are initially  determined by VA’s qualification standards for VA CRNAs, VA medical  facilities have the option of adjusting these salaries to recruit and retain  VA CRNAs. When adjusting VA CRNA salaries, VA medical facilities are  required to use a process known as LPS. The system is intended to help  VA medical facilities determine whether to adjust VA CRNA salaries to be  regionally competitive. VA’s LPS supports these goals by providing  information on salaries paid to CRNAs in a facility’s local market area. To  collect data for the LPS, medical facility directors, who are responsible for  their facility’s LPS, can either use a salary survey conducted by another  entity or conduct their own survey in order to determine the CRNA salary  levels paid by health care establishments in the local market area. VA’s  LPS policy requires that a medical facility director initiate an LPS survey if  the director determines that a significant pay-related staffing problem  exists or is likely to exist for any occupation or specialty.
VA’s LPS policy instructs medical facilities to use a survey conducted by  the Bureau of Labor Statistics (BLS); however, if data from this survey are  not available or not current, facilities are to use a third-party locality pay  survey. Third-party surveys include those that are purchased from a third- party service that collects compensation data on salaries of health care  occupations. These surveys can also include salary data collected by local  hospital associations for their member health care establishments. When  BLS or other third-party surveys are not available or do not contain  sufficient salary data, facilities are to conduct their own locality pay  survey.
Under VA’s LPS policy, a third-party locality pay survey must include data  from at least three non-VA health care establishments, such as hospitals  and outpatient clinics. VA’s LPS policy requires that a third-party survey  cover an appropriate local market area, which is defined by VA as one that  includes the county in which the VA medical facility is located and  includes health care establishments that compete for the same type of  clinical employees, such as CRNAs. The health care establishments that  participate in a third-party survey should provide job descriptions that  include the duties, responsibilities, and education and experience  requirements of CRNAs and should be able to be readily job-matched to  VA’s description of the VA CRNA grade levels.
If a VA medical facility conducts its own LPS survey, VA’s LPS policy  requires that the geographic area surveyed be defined. In order to be valid,  three health care establishments must have job descriptions for CRNAs  that can be job-matched to VA CRNA grade levels. A VA medical facility  may expand the geographic area surveyed when the surveyed area will not  adequately reflect the local market area salaries for CRNAs or there are  less than three job matches.
Once the survey is completed, a facility’s HR officer reports the results to  the medical facility director and based on the survey data, recommends  whether to adjust VA CRNA salaries. The facility director makes the final  decision on whether to adjust VA CRNA salaries and, therefore, may  choose not to adjust existing salaries regardless of what the survey data  show, according to VA’s policy. VA medical facility directors consider the  competing demands for funding across the facility when making decisions  about VA CRNA salary increases.
VA’s LPS policy requires VA medical facilities to report annually to VA  headquarters on VA CRNA staffing, such as the vacancy and turnover rates  for VA CRNAs within the recent fiscal year. VA medical facilities are also  required to report whether the facility had a pay-related staffing problem  as determined by the medical facility director and whether a medical  facility director used a locality pay survey to determine if VA CRNA  salaries should be adjusted. VA reported that in 2005 and 2006 all VA  medical facility directors who determined that a significant pay-related  staffing problem existed or was likely to exist at their facility used a  locality pay survey to determine whether VA CRNA salaries should be  adjusted.
section_title: Some Medical Facilities Use the Key Recruitment and Retention Mechanisms, Though in Some Cases LPS Was Used Incorrectly
paragraphs: Each of the three key recruitment and retention mechanisms—bonuses,  education payment programs, and VA’s LPS—are used by some VA  medical facilities. We found in fiscal years 2005 or 2006, of those VA  medical facilities that hired VA CRNAs, just over one-third gave  recruitment bonuses. In addition, less than one-third of all VA medical  facilities that employ VA CRNAs gave retention bonuses, and a few gave  relocation bonuses. We also found, according to data we obtained from  VA, that all who applied and were eligible for EISP and EDRP funds for  CRNA training received these funds. Further, more than half of the VA  medical facilities responding to our survey reported using VA’s LPS in 2005  and in 2006 to determine whether to adjust VA CRNA salaries. However,  five of the eight VA medical facilities we visited did not fully follow VA’s  LPS policy in either 2005 or 2006, and officials at these facilities did not  appear to understand certain aspects of the policy. These problems  indicate VA has not provided adequate training on the LPS process since  the policy was changed in 2001.
subsections: section_title: Some VA Medical Facilities Give Bonuses to VA CRNAs
paragraphs: According to VA data, of the 47 VA medical facilities that hired a VA CRNA  in fiscal year 2005, 18 of these facilities paid recruitment bonuses. Five  facilities gave recruitment bonuses of $15,000 or more, seven gave  recruitment bonuses of between $10,000 and $14,999, and five gave  recruitment bonuses of less than $10,000. One facility gave recruitment  bonuses in two of the categories—the more than $15,000 and less than  $15,000 categories. In fiscal year 2006, of the 43 VA medical facilities that  hired a VA CRNA, 15 of these facilities paid recruitment bonuses. Five  facilities gave recruitment bonuses of $15,000 or more, six gave  recruitment bonuses of between $10,000 and $14,999, and three gave  recruitment bonuses of less than $10,000. One facility gave recruitment  bonuses in two of the categories—the more than $15,000 and less than  $10,000 categories. According to VA HR officers who responded to our  survey, facilities gave recruitment bonuses to VA CRNAs because VA  CRNA salaries at VA facilities were lower than local market area salaries.
According to VA data, 32 and 36 VA medical facilities gave retention  bonuses to VA CRNAs in fiscal years 2005 and 2006, respectively. The  majority of these facilities gave a retention bonus of $10,000 or more.  According to more than one-fourth of VA medical facility HR officers who  responded to our survey, retention bonuses are used to make VA CRNA  salaries competitive with CRNA salaries in local market areas.
Compared with recruitment and retention bonuses, relocation bonuses are  less frequently used by VA medical facilities. According to VA data, two VA  medical facilities paid relocation bonuses of about $31,000 in fiscal year  2005 to two VA CRNAs. In fiscal year 2006, VA data show that three VA  medical facilities gave relocation bonuses to four VA CRNAs, with three  bonuses ranging from $8,000 to $10,000, and one bonus of $25,000.
section_title: VA Medical Facilities Use VA’s Education Payment Programs for Nurse Anesthetist Training
paragraphs: VA medical facilities use VA’s education payment programs, EISP and  EDRP, to expand the VA CRNA workforce. According to data we obtained  from VA, from March 2000 through September 2006, 25 VA registered  nurses at various medical facilities that were enrolled in nurse anesthetist  training programs applied for and were awarded EISP scholarships. For  fiscal years 2005 and 2006, 13 registered nurses received EISP  scholarships, of which 8 attended the joint DOD/VA CRNA training  program. Two of the eight VA medical facilities we visited had approved  an EISP award for students attending the joint DOD/VA CRNA training  program.
In addition to the EISP scholarships, VA CRNAs may be eligible for VA’s  EDRP funds. VA data show that seven VA CRNAs applied for and were  approved to receive tuition reimbursement through the EDRP in fiscal  year 2005, and in fiscal year 2006, three VA CRNAs applied and were  approved to receive this funding. Two of the eight VA medical facilities we  visited had approved a total of three EDRP awards. At one of these  facilities, officials told us that they had remaining EDRP funds in fiscal  year 2006 because there were no employee applications, so these funds  were not used. VA medical facility officials determine which occupations  have priority in receiving EDRP funds based on difficulty in recruiting  these occupations.
section_title: A Majority of Medical Facilities Use VA’s LPS to Determine Whether to Adjust VA CRNA Salaries, but Instances of Incorrect Use Indicate Inadequate Training on LPS Policy
paragraphs: According to VA’s 2005 data, 86 VA medical facilities that employ VA  CRNAs used VA’s LPS to determine whether to adjust salaries of VA  CRNAs at their facilities. Of those that used VA’s LPS, 63 facilities used a  third-party survey to obtain data on local market area salary rates for  CRNAs.
While VA’s data showed that a majority of VA medical facilities that  employ VA CRNAs are using VA’s LPS, we found that five of the eight  facilities we visited did not use the LPS in accordance with VA’s LPS  policy in 2005 or 2006. The policy is designed to ensure that facility  officials have a mechanism to determine whether their VA CRNA salaries  should be adjusted to be competitive in recruiting and retaining VA  CRNAs. By not fully following this policy, officials at these five facilities  are making decisions to adjust or not adjust VA CRNA salaries without  sufficient data on the salaries of CRNAs in their local market areas.
At the five VA medical facilities that did not fully follow VA’s LPS policy  correctly, facility officials with oversight responsibility for the LPS were  not knowledgeable about certain aspects of the LPS policy. One facility  official told us that the third-party salary survey data were determined to  be insufficient, so the facility used salary data from a Hot Jobs Web site to  determine whether to adjust VA CRNA salaries. The official was unaware  that this data source cannot be considered valid survey data for the  purpose of adjusting VA CRNA salaries. At one facility, officials applied an  outdated methodology for adjusting VA CRNA salaries and in doing so did  not fully follow the most current LPS policy. The outdated policy only  permitted VA medical facility officials to adjust salary rates for each VA  CRNA grade at 5 percent above or below the beginning CRNA salary rates  in local market areas. In contrast, VA’s current LPS policy allows facility  officials to adjust these salaries in order to be competitive. The remaining  three facilities did not have sufficient salary data to determine whether VA  CRNA salaries should be adjusted, and believed they could not use salary  data of CRNAs that work for organizations that contract CRNA anesthesia  services. These officials were unaware that VA’s policy allows them to  expand their data collection to include this type of salary data if the data  they had previously collected were insufficient.
The problems some VA medical facilities had fully following VA’s LPS  policy, along with the explanations of facility officials, indicate that VA has  not provided adequate training on its LPS policy. Currently, VA medical  facility officials can refer to VA’s LPS policy when they have questions, or  they can contact VA headquarters, according to a VA official. VA last  changed its LPS policy in 2001, which resulted in a number of changes,  such as the use of third-party surveys and the use of salary data of CRNAs  that work for organizations that contract anesthesia services. VA,  however, has not conducted nationwide training on its LPS policy since  1995. As a result, VA medical facility officials have not received LPS  training that reflects VA’s current LPS policy, and accordingly, cannot  ensure that VA CRNA salaries have been adjusted as needed to be  competitive.
VA is in the process of developing a Web-based training course for the LPS  that VA medical facility officials can complete on-line. VA is early in the  development of this project because it is assigned to two staff that have  other job priorities, according to a VA official. Because VA has not made  the training a priority, it has not established a time frame for finalizing the  development and implementation of this training course.
section_title: Conclusions
paragraphs: VA’s difficulty recruiting and retaining VA CRNAs has created workforce  challenges that the department must confront now and in the future.  Because a significant number of VA CRNAs plan to retire or leave VA’s  health care system in the next 5 years and because many VA medical  facilities do not have salaries that attract CRNAs, some VA medical  facilities may face significant challenges delivering anesthesia services to  veterans. It is important that VA maximize its ability to recruit and retain  VA CRNAs. A key mechanism VA medical facilities have is the LPS, which  is used to help facilities determine to what extent VA CRNA salaries are  competitive with the CRNA salaries paid by competing health care  establishments.
While the LPS is used across VA, at five of eight facilities we visited  officials used it incorrectly and appeared unaware of some of the policy  requirements related to the LPS. The lapses at the five facilities reveal a  larger problem: VA has not taken the necessary steps to ensure that VA  officials are aware of the current LPS policy and can use it correctly. VA  last provided training on the LPS in 1995, but since then some aspects of  the policy have changed. While VA has indicated that it is developing Web- based training on the LPS, VA has not made the development of this  training a priority or indicated when the training will be available. Current  training on the LPS is necessary to help ensure that VA medical facilities  are competitive as an employer by allowing medical facility officials to  make salary decisions for VA CRNAs with sufficient information on the  CRNA salaries in their local market areas.
section_title: Recommendation for Executive Action
paragraphs: To improve VA’s ability to recruit and retain VA CRNAs, we recommend  that the Secretary of Veterans Affairs direct the Assistant Secretary for  Human Resources and Administration to expedite development and  implementation of the training course on VA’s LPS policy for VA medical  facility officials responsible for compliance with the policy.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, VA generally agreed with our  conclusions. VA also concurred with our recommendation to expedite the  development and implementation of the training course on VA’s LPS  policy and stated that it has developed a draft action plan for training staff  on this policy and anticipates the on-line training course will be available  by the end of fiscal year 2008. VA provided technical comments, which we  have incorporated as appropriate.
VA expressed reservations about our reliance on information obtained  from VA CRNAs and VA chief anesthesiologists who responded to our  surveys. VA stated that those being surveyed may have inflated their  perceptions of recruitment and retention challenges with the hope that  findings may encourage additional resources for their professions. We  recognize there is a potential for bias in self-reported data; however, we  used other information to corroborate our survey findings. Specifically, we  also used information obtained from interviews with VA headquarters  officials, as well as survey data obtained from VA medical facilities’ human  resources officers.
VA expressed concern about our projected VA CRNA attrition rate. On the  basis of VA CRNAs who reported they would retire or leave the VA within  the next 5 years, we projected a 26 percent attrition rate of VA CRNAs  systemwide. We anticipate that this rate will vary by VA medical facility,  with some facilities having a rate of 50 percent or higher and others having  a much lower rate. In commenting on our projected VA CRNA attrition  rate, VA noted that the 26 percent attrition rate indicated that the VA  CRNA turnover rate during the 5 years would average 5.2 percent annually  and that this turnover rate was low compared to VA’s actual turnover rate  for VA CRNAs, which has ranged from a low of 10.02 percent to a high of  15.6 percent.
VA also commented that our report highlighted the fact that more than   50 percent of VA CRNAs are over 51 years of age and nearing the  retirement eligibility age, implying that VA is at risk of losing a significant  number of VA CRNAs to retirement. VA stated that these VA CRNAs are  not necessarily retirement eligible or inclined to retire when eligible. This  information was included in the report with other demographic  information about VA CRNAs to provide some prospective on VA’s CRNA  workforce. VA’s written comments are reprinted in appendix VI.
We are sending copies of this report to the Secretary of Veterans Affairs  and other interested parties. We will also provide copies to others upon  request. In addition, the report is available at no charge on the GAO Web  site at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or at Ekstrandl@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs can be found on  the last page of this report. GAO staff members who made major  contributions to this report are listed in appendix VII.
section_title: Appendix I: Scope and Methodology
paragraphs: We examined the Department of Veterans Affairs’ (VA) certified registered  nurse anesthetists (CRNA) workforce issues and the mechanisms that VA  medical facilities use to recruit and retain VA employed CRNAs (VA  CRNA). Specifically, we (1) identified workforce challenges that VA  medical facilities may experience related to VA CRNAs, (2) identified the  key mechanisms that VA medical facility officials can use to recruit and  retain VA CRNAs, and (3) determined the extent to which VA medical  facilities use the key mechanisms to recruit and retain VA CRNAs.
To identify workforce challenges that VA medical facilities experience  related to VA CRNAs, we analyzed data from our three Web-based surveys,  which captured information from fiscal years 2005 and 2006. Each of the  three surveys contained questions that helped us identify current and  future challenges that VA medical facilities will experience in recruiting  and retaining VA CRNAs. The first survey was administered in December  2006 to 474 VA CRNAs. We contacted officials at all VA medical facilities  to determine whether they employed VA CRNAs both on a full-time or  part-time basis, and for those that did, obtained e-mail addresses for the  VA CRNAs. We verified our list of VA CRNAs with a list obtained from  VA’s Personnel Accounting Integrated Data system, which houses VA’s  payroll and human resources (HR) information. This survey of VA CRNAs  covered various workforce issues, including their plans to retire or leave  VA’s health care system, the use of contract CRNAs to supplement VA  CRNAs, and recruitment and retention of VA CRNAs. The survey had an  overall response rate of 76 percent, which allowed us to generalize to the  VA CRNA population. The second survey was administered in May 2007 to  125 chief anesthesiologists working in the VA medical system. We  obtained the contact list for chief anesthesiologists from VA headquarters  anesthesia services. This survey covered CRNA workforce issues,  including VA CRNA salaries, staffing, recruitment and retention, the effect  of vacancies on medical facilities’ services, and the use of contract CRNAs.  The survey had an overall response rate of 92 percent, which allowed us to  generalize to all VA medical facilities that employ VA CRNAs. The third  survey was administered in May 2007 to HR officers at 170 VA medical  facilities. We obtained the contact list for VA HR officers from VA. The  survey covered CRNA workforce issues including salary, locality pay  surveys, and bonuses given for recruitment and retention. This survey had  an overall response rate of 85 percent, which allowed us to generalize to  all VA medical facilities that employ VA CRNAs. We also obtained VA  medical facility data on the number of VA CRNA vacancies and VA CRNA  vacancy rates. These data are reported by VA medical facilities to VA  headquarters and were included in VA’s 2006 annual report to Congress on  staffing.
Additionally, we obtained VA CRNA salary schedules for 2005, 2006, and  2007 from VA headquarters for each VA medical facility. These salary  schedules contained the VA CRNA salary rates for grades I through V and  steps 1 to 12 for each of the grades. Using these salary schedules, we  compared VA CRNA salaries with CRNA salary data we obtained from the  American Association of Nurse Anesthetists (AANA), a professional  organization for CRNAs. AANA’s salary data for CRNAs was compiled in  its 2006 Practice Profile Survey—a national survey of AANA’s  membership—and included self-reported 2005 salary information that was  reported by state. To compare salaries for 2006 and 2007, we projected  the 2005 AANA salary data using the Bureau of Labor Statistics (BLS)  employment cost index. According to VA officials, VA is seeking  legislation that would increase VA CRNAs’ maximum statutory salary cap.  On the basis of this proposed legislation, we used VA’s 2007 VA CRNA  maximum statutory salary cap that was $136,200 and would increase to  $145,400 with the proposed legislation. We compared VA’s proposed  increase to AANA’s 2007 salary data for each state in which a VA medical  facility is located to determine whether increasing VA’s maximum  statutory salary cap as VA proposes would make VA CRNA salaries  competitive with local market area salaries. We used the 90th percentile  AANA CRNA salary in each state for this comparison because this  percentile represents the higher end of the salary range for the local  market area. In addition, we compared VA CRNA qualification standards  to VA’s proposed revision, which would increase starting salaries for new  graduate VA CRNAs from grade I to grade II. We compared 2007 VA CRNA  salary schedules at the grade II level for each facility to AANA’s CRNA  salary data for each state in which a VA medical facility is located to  determine whether grade II salaries would be competitive with local  market area salaries. We used the 25th percentile AANA salary in each  state for this comparison because this percentile represents the lower end  of the salary range for the local market area.
We interviewed the director of Kaiser Permanente’s school of anesthesia  for nurse anesthetists to identify what steps this director takes to ensure it  has a sufficient number of CRNAs to deliver anesthesia services and to  learn the indicators used to identify a CRNA shortage or potential future  shortage. We also interviewed the director of VA headquarters anesthesia  services to obtain information on VA CRNA workforce challenges.
To determine the key mechanisms that VA medical facilities use to recruit  and retain VA CRNAs, we reviewed VA’s policies and directives related to  VA CRNAs and obtained reports on VA CRNA salaries. We also reviewed  and analyzed policies, legislation, and regulations on VA’s locality pay  system (LPS), and VA’s authority to give recruitment, relocation, and  retention bonuses to VA CRNAs. In addition, we reviewed legislation and  policies related to two VA employee education programs—the Employee  Incentive Scholarship Program (EISP) and the Education Debt Reduction  Program (EDRP). We interviewed officials at VA headquarters, including  HR officers. We interviewed chief anesthesiologists, VA CRNAs, HR  officers, and other officials at selected VA medical facilities. We also  interviewed officials from VA’s Healthcare Retention and Recruitment  Office (HRRO), located in New Orleans, Louisiana, to obtain information  about the implementation of EISP and EDRP.
To determine the extent to which VA medical facilities use the key  mechanisms to recruit and retain VA CRNAs, we analyzed data from our  three Web-based surveys. We analyzed data included in VA’s 2006 annual  report to Congress on staffing, which included information on each VA  medical facility’s use of LPS. We also obtained data from VA headquarters  on the number and amount of recruitment, relocation, and retention  bonuses paid to VA CRNAs in fiscal years 2005 and 2006. Additionally, we  obtained data from VA’s HRRO on funds distributed to VA medical  facilities for the EISP and EDRP.
To gain further information on the extent to which VA medical facilities  use the key mechanisms, we visited eight VA medical facilities. We  selected these facilities to obtain anecdotal examples, which are  supported by our data collection. The findings from these eight facilities  cannot be generalized to all VA medical facilities. We also selected the  facilities based on geographical variation and because they employed VA  CRNAs. The eight VA medical facilities we visited are located in Denver,  Colorado; Houston, Texas; Minneapolis, Minnesota; New York, New York;  Portland, Oregon; Seattle, Washington; Tampa, Florida; and Togus, Maine.  At each medical facility, we interviewed chief anesthesiologists, VA  CRNAs, HR officers, and other facility officials. In addition, we obtained  copies of locality pay surveys for 2005 and 2006 from the eight medical  facilities.
We obtained data from VA headquarters and AANA and surveyed VA  CRNAs, VA chief anesthesiologists, and VA HR officers. Data obtained  from VA headquarters included CRNA salaries for each VA medical facility  by VA CRNA grade and step, medical facility VA CRNA vacancy rates, and  type of VA CRNA locality pay survey used at each VA medical facility. We  also obtained from VA headquarters data from its Personnel Accounting  Integrated Data (PAID) system that contained the amounts of individual  VA CRNA recruitment, relocation, and retention bonuses. We contacted  VA officials responsible for these data sets to gain an understanding of the  completeness and accuracy of the data VA headquarters provided and  whether quality checks were performed by VA on these data. In addition,  we obtained 2005 salary data from AANA as reported in their members’  annual survey. We interviewed AANA officials to determine the quality  checks they performed on the data from this survey. The AANA members’  survey has an overall response rate of 60 percent and has had a similar  response rate for the last 25 years. AANA noted that the income data from  the survey is self reported by AANA members and in some of the smaller  states the number of respondents was small. We also conducted Web- based surveys of VA CRNAs, VA chief anesthesiologists, and VA HR  officers to identify workforce challenges that VA medical facilities  experience related to VA CRNAs. A systematic review of the returned  questionnaires was performed, checking for factors such as key questions  being answered, skip patterns being followed, written entries clearly  entered, and quantitative entries within scope. On the basis of our  assessment of the reliability and limitations of VA headquarters’ data,  AANA members’ survey data, and our three Web-based surveys, we  determined that the data used in this report were adequate for our  purposes.
We conducted our work from June 2006 through October 2007 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Analysis of GAO Survey of Certified Registered Nurse Anesthetists Employed by VA
paragraphs: To obtain the views of VA CRNAs on various recruitment and retention  issues, we conducted a Web-based survey of all VA CRNAs employed at  VA medical facilities. The questionnaire contained questions on topics  such as CRNAs’ views on recruitment and retention incentives, use of  contract/agency CRNAs at the medical facility where they work, and the  CRNAs’ plans to leave the VA medical facility in the next 5 years. Not all  column totals will add to 100 percent due to rounding, multiple answers to  questions that ask respondents to check all that apply, and no response by  VA CRNAs to some questions.
Q1. Of the factors listed, which five factors attracted you to work at this    VA medical facility?
Checked  (percentage)
Q2. Of the factors listed, which five factors keep you working at this VA    medical facility?
Checked  (percentage)
Q3. Are you eligible to retire now or within the next 5 years? (percentage)
Q4. If you are eligible or when you become eligible, do you plan to retire?
Checked (percentage)
Q5. Of the factors listed, which three factors would encourage you to    postpone retiring?
Checked  (percentage)
Q6. After you retire from the federal government, do you plan to work as a   CRNA outside of VA’s health care system?
Checked (percentage)
Q7. Do you plan to leave this VA medical facility within the next 5 years?
Checked  (percentage)
Q8. Of the factors listed, which three factors not currently available at this    VA medical facility would keep you working here?
Checked  (percentage)
Q9. Has this VA medical facility used contract/agency CRNAs during the    last 2 years (from October 1, 2004 through September 30, 2006)?
Checked (percentage)
Q10. Is there a shortage of CRNAs at this VA medical facility?
Checked (percentage)
Q11. Of the factors listed, which five factors would strengthen recruitment    of CRNAs at this VA medical facility?
Checked  (percentage)
section_title: Appendix III: Analysis of GAO Survey of Chief Anesthesiologists Employed by VA
paragraphs: To obtain the views of VA’s chief anesthesiologists on various recruitment  and retention issues, we conducted a Web-based survey of all VA chief  anesthesiologists employed at VA medical facilities. The questionnaire  contained questions on topics, such as the chief anesthesiologists’ views  on CRNA recruitment and retention issues; CRNA vacancies, the effects of  the vacancies, and the time it takes to fill CRNA vacancies; whether CRNA  salaries at VA medical facilities are competitive with CRNA salaries in  local market areas; and the use of contract CRNAs. Not all column totals  will add to 100 percent due to rounding, multiple answers to questions that  ask respondents to check all that apply, and no response by VA chief  anesthesiologists to some questions.
Q1. How many months on average did it take to fill a vacant VA CRNA   position from the time the request to fill the vacancy was approved to  the time the vacancy was filled?
Checked (percentage)
Q2. What were the effects on this facility of having VA CRNA vacancies? (percentage)
Q3. As of September 30, 2006, did this facility have a shortage of CRNAs   even though all its VA CRNA allocated positions were filled?
Checked (percentage)
Q4. What were the effects on this facility of having a shortage of VA    CRNAs?
Checked  (percentage)
Q5. Has this facility had any difficulty in recruiting CRNAs in the last    2 years (October 1, 2004 – September 30, 2006)?
Checked (percentage)
Q6. What are the reasons this facility has had difficulties in recruiting    CRNAs? (percentage)
Q7. Has this facility had difficulty with VA CRNAs leaving or with retaining    VA CRNAs in the last 2 years (October 1, 2004–September 30, 2006)?
Checked  (percentage)
Q8. What are the reasons this facility has had difficulty with VA CRNAs   leaving or with retaining VA CRNAs? (percentage)
Q9. How did VA CRNA annual salaries at this facility generally compare    with local market area CRNA salaries from October 1, 2004–   September 30, 2005 for new graduate CRNAs?
Checked  (percentage)
Q10. How did VA CRNA annual salaries at this facility generally compare    with local market area CRNA salaries from October 1, 2004–   September 30, 2005 for experienced CRNAs?
Checked  (percentage)
Q11. If this facility’s 2005 VA CRNA salaries were higher than local market    area salaries, how much higher were the salaries for new graduate    CRNAs?
Checked (percentage)
Q.12. If this facility’s 2005 VA CRNA salaries were higher than local market   area salaries, how much higher were the salaries for experienced   CRNAs?
Checked (percentage)
Q13. If this facility’s 2005 VA CRNA salaries were lower than local market    area salaries, how much lower were the salaries for new graduate    CRNAs?
Checked (percentage)
Q14. If this facility’s 2005 VA CRNA salaries were lower than local market    area salaries, how much lower were the salaries for experienced    CRNAs?
Checked (percentage)
Q15. How did VA CRNA annual salaries at this facility generally compare    with local market area CRNA salaries from October 1, 2005–   September 30, 2006 for new graduate CRNAs?
Checked  (percentage)
Q16. How did VA CRNA annual salaries at this facility generally compare    with local market area CRNA salaries from October 1, 2005–   September 30, 2006 for experienced CRNAs?
Checked  (percentage)
Q17. If this facility’s 2006 VA CRNA salaries were higher than local market    area salaries, how much lower were the salaries for new graduate    CRNAs?
Checked (percentage)
Q18. If this facility’s 2006 VA CRNA salaries were higher than local market    area salaries, how much lower were the salaries for experienced    CRNAs?
Checked (percentage)
Q19. If this facility’s 2006 VA CRNA salaries were lower than local market    area salaries, how much lower were the salaries for new graduate    CRNAs?
Checked (percentage)
Q20. If this facility’s 2006 VA CRNA salaries were lower than local market    area salaries, how much lower were the salaries for experienced    CRNAs?
Checked (percentage)
Q21. What were the reasons this facility used contract CRNAs from    October 1, 2004-September 30, 2005? (percentage)
Q22. What were the reasons this facility used contract CRNAs from    October 1, 2005-September 30, 2006? (percentage)
section_title: Appendix IV: Analysis of GAO Survey of VA Medical Facility Human Resources Officers
paragraphs: To obtain the views of VA human resources officers on various  recruitment and retention issues, we conducted a Web-based survey of VA  human resources officers, one representing each VA medical facility. The  questionnaire contained questions related to CRNAs recruitment and  retention issues, such as CRNA salary, locality pay surveys, and bonuses  given for recruitment and retention. Not all column totals will add to   100 percent due to rounding, multiple answers to questions that ask  respondents to check all that apply, and no response by VA medical  facility human resources officers to some questions.
Q1. Over the last 2 years what criteria were used to determine whether a    VA CRNA was paid a recruitment incentive? (percentage) (percentage)
Q2. Over the last 2 years what criteria were used to determine whether a    VA CRNA was paid a relocation incentive? (percentage) (percentage)
Q3. Over the last 2 years what criteria were used to determine whether a    VA CRNA was paid a retention incentive? (percentage)
Q4. What types of CRNA salary information were included in the 2005    locality pay survey? (percentage)
Q5. In the 2005 locality pay survey, did a sufficient number of respondents    provide survey data?
Checked (percentage)
If yes, what actions did Human Resources take to address the insufficient  number of survey respondents?
Checked  (percentage)
Q6. Overall were you satisfied with the CRNA salary information you    received in the 2005 locality pay survey?
Checked (percentage)
Q7. How did 2005 VA CRNA annual salaries at this facility generally   compare with local market area annual salaries for new graduate   CRNAs?
Checked  (percentage)
Q8. How did 2005 VA CRNA annual salaries at this facility generally   compare with local market area annual salaries for experienced   CRNAs?
Checked  (percentage)
Q9. If this facility’s 2005 VA CRNA annual salaries were higher than local   market area salaries, how much higher were the VA CRNA salaries for  new graduate CRNAs?
Checked (percentage)
Q10. If this facility’s 2005 VA CRNA annual salaries were higher than local    market area salaries, how much higher were the VA CRNA salaries    for experienced CRNAs?
Checked (percentage)
Q11. If this facility’s 2005 VA CRNA annual salaries were lower than local    market area salaries, how much lower were the VA CRNA salaries for    new graduate CRNAs?
Checked (percentage)
Q12. If this facility’s 2005 VA CRNA annual salaries were lower than local    market area salaries, how much lower were the VA CRNA salaries for    experienced CRNAs?
Checked (percentage)
Q13. What types of CRNA salary information were included in the 2006    locality pay survey?
Checked  (percentage)
Q14. In the 2006 locality pay survey, did a sufficient number of    respondents provide survey data?
Checked (percentage)
Q15. Overall were you satisfied with the CRNA salary information you    received in the 2006 locality pay survey?
Checked (percentage)
Q16. How did 2006 VA CRNA annual salaries at this facility generally    compare with local market area annual salaries for new graduate    CRNAs?
Checked  (percentage)
Q17. How did 2006 VA CRNA annual salaries at this facility generally    compare with local market area annual salaries for experienced    CRNAs?
Checked  (percentage)
Q18. If this facility’s 2006 VA CRNA annual salaries were higher than local    market area salaries, how much higher were the VA CRNA salaries    for new graduate CRNAs?
Checked (percentage)
Q19. If this facility’s 2006 VA CRNA annual salaries were higher than local    market area salaries, how much higher were the VA CRNA salaries    for experienced CRNAs?
Checked (percentage)
Q20. If this facility’s 2006 VA CRNA annual salaries were lower than local    market area salaries, how much lower were the VA CRNA salaries for    new graduate CRNAs?
Checked (percentage)
Q21. If this facility’s 2006 VA CRNA annual salaries were lower than local    market area salaries, how much lower were the VA CRNA salaries for    experienced CRNAs?
Checked (percentage)
Q22. Has this facility ever requested approval to rehire VA CRNAs retired    from federal service without affecting their retirement pay under the    provisions of the Health Care Programs Enhancement Act of 2001    (P.L. 107-135)?
Checked (percentage)
section_title: Appendix V: Description of Education and Training Requirements for Anesthesia Practitioners
subsections: section_title: Anesthesiologists
paragraphs: Certified Registered Nurse  Anesthetists (CRNA)
Anesthesiologist Assistants (AA)
Anesthesiologists are physicians  who administer anesthesia services  to relieve pain and medically  manage a patient’s vital life  functions throughout any surgical,  obstetrical, or other medical  procedure.
CRNAs are registered nurses that  work with anesthesiologists,  surgeons, or dentists. In some  states, CRNAs do not have to have  direct supervision.
AAs are allied health professionals  that work under the supervision of a  licensed anesthesiologist to deliver  anesthesia services.
Must have a bachelor’s degree to  enter medical school. During  medical school, students rotate  through internal medicine, family  practice, obstetrics, gynecology,  pediatrics, psychiatry and surgery.  Following medical school, they have  a 4-year anesthesiology residency  program, which includes a year of  clinical medicine, two years of  anesthesiology, and one year of  concentrated study and experience  with anesthetic complications.  Following residency, they may  pursue additional training in specific  areas of anesthesiology.
Registered nurses with a bachelor’s  degree, current licensure, and at  least 1 year’s experience in an  acute care setting. Trained in  anesthesia techniques and  procedures for all types of surgery  and obstetrics. Must have  performed 550 anesthesia cases to  be eligible for certification.
Premedical undergraduate courses.  Completion of an accredited  anesthesiologist assistant program.  Trained in patient monitoring,  anesthesia delivery systems,  patient assessment, and life support  systems. Typically, have a minimum  of 2,000 clinical hours in direct  patient anesthesia-related care.
129 medical schools with  anesthesia programs in the United  States.
106 accredited graduate-level  programs in the United States.
4 programs within a school of  medicine in the United States.
4 years of undergraduate school;   4 years of medical school; and  4 years of residency.
24–36 months in a CRNA training  program.
24–28 months in an AA training  program.
Doctor of Medicine (MD) or a Doctor  of Osteopathic Medicine (DO).
Masters or doctoral degree from an  accredited CRNA education  program.
Master of Science degree.
Must obtain a state license to  practice in a state.  Anesthesiologists may obtain board  certification by passing an  examination. They must periodically  meet continuing medical education  credit requirements that vary by  state.
CRNAs must hold a current  registered nurse license and pass a  national certification exam to obtain  a national certification. They  recertify every 2 years by obtaining  40 continuing medical education  credits and must attest to being  involved in 850 hours of practice  involving anesthesia.
At a minimum, AAs must obtain a  national certification and must  recertify every 2 years by submitting  40 continuing medical education  credits. Every sixth year, AAs must  pass a written board examination.
section_title: Appendix VI: Comments from the Department Of Veterans Affairs
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann, Assistant  Director; N. Rotimi Adebonojo; Michelle M. Alletto; Mary Ann Curran;  Linda Diggs; Martha A. Fisher; Krister Friday; Molly Ryan;   James R. Walker; and Suzanne Worth made key contributions to this  report.