VHA's health care mission is broad in that it provides veterans with a wide range of health care services. These services include primary care and surgery and unique specialized care, such as treatment for post-traumatic stress disorder, traumatic brain injury, and readjustment counseling. VHA is also a leader in medical research and the largest provider of health care training in the United States. As such, each medical center hires employees in a wide range of clinical and administrative professions, from nurses and physicians to hospital administrators, police, and housekeepers. These employees are covered by three types of personnel systems: Title 5 of the U.S. Code (Title 5): The majority of federal employees across the government are hired under the authority of Title 5; at VHA, employees under this personnel system hold positions such as police officers, accountants, and HR management. Title 38 of the U.S. Code (Title 38): VA's separate personnel system for appointing medical staff including physicians, dentists, and registered nurses. These appointments are made based on an individual's qualifications and professional attainments in accordance with standards established by VA's Secretary. Title 38-Hybrid: Employees under this personnel system hold positions such as respiratory, occupational, or physical therapists; social workers; and pharmacists. This system combines elements of both Title 5 (such as for performance appraisal, leave, and duty hours) and Title 38 (such as for appointment, advancement, and pay). Each of these personnel systems has different requirements (and flexibilities) related to recruitment and hiring, performance management, and other areas served by VHA's HR staff. VHA's HR functions are decentralized. Each of VHA's VISNs has an HR office that oversees the medical center-level HR offices within its network. In general, each VA medical center has its own HR office led by an HR officer. Individual HR offices are responsible for managing employee recruitment and staffing, employee benefits, compensation, employee and labor relations, and overseeing the annual employee performance appraisal process. Medical center HR offices also provide HR services to employees at VHA's community-based living centers, rehabilitation centers, and outpatient centers. VHA's HR staff are classified as either an HR specialist, who manages, supervises, and delivers HR products and services; or an HR assistant, who provides administrative support to HR specialists. In our 2016 report on VHA clinical employee retention, we noted that in 2015 VHA had about 195,900 clinical employees in 45 types of occupations. To meet the growing demand for care, VHA implemented a number of targeted hiring initiatives, such as a mental health hiring initiative, which brought on about 5,300 staff nationwide from 2012 to 2013. Despite these hiring efforts, we and others have expressed concerns about VHA's ability to ensure that it has the appropriate clinical workforce to meet the current and future needs of veterans, due to factors such as national shortages and increased competition for clinical employees in hard-to-fill occupations. VHA officials have expressed concern with their hiring capabilities since 2014, when a well-publicized series of events called into question the ability of veterans to gain timely access to care from VHA. Our 2016 report found that for the 5 VHA clinical occupations with the largest staffing shortages (as identified by the VA Office of Inspector General in January 2015), the number of employees that VHA lost increased each year, from about 5,900 employees in fiscal year 2011 to about 7,700 in fiscal year 2015 (the 5 occupations were physicians, registered nurses, physician assistants, psychologists, and physical therapists). This attrition accounted for about 50 percent of VHA's total losses across all clinical occupations during this period. We found a similar trend for all clinical occupations across VHA--losses increased annually during this period. (See table 1). From fiscal year 2011 through 2015, occupation loss rates for each of the 5 shortage occupations varied annually, though most saw an overall increase in losses during this period (see figure 1). Physician assistants consistently had the highest loss rate among the 5 shortage occupations. The loss rate for physician assistants increased from 9.3 to 10.9 percent during this period. The loss rate for physical therapists decreased from fiscal year 2011 to 2012 (from 8.3 to 6.4 percent), but then increased to 8.0 percent in fiscal year 2015. In addition to our review of VHA's 5 shortage occupations, we also identified the 10 clinical occupations within VHA with the highest loss rates as of fiscal year 2015 (they were physician assistant, medical support assistant, medical supply aide and technician, optometrist, nursing assistant, medical records technician, health technician (optometry), physician, practical nurse, and medical records administration). The loss rates for these 10 occupations also varied (ranging from 5.3 percent to 10.9 percent each year from fiscal years 2011 through 2015). We found that 2 of the 5 shortage occupations-- physician assistants and physicians--were among this group of the 10 highest loss-rate occupations each year from fiscal year 2011 through 2015. Additionally, 2 other occupations--medical support assistants and nursing assistants--were also consistently among this group of the 10 highest loss-rate occupations each year during this period. The 6 remaining occupations were technical positions that were generally small in overall number, such as medical supply aides and technicians. According to VHA HR officials, employees in these occupations generally do not require specialized education or licensing; thus, they tend to be more easily replaced than those in the 5 shortage occupations. According to VHA's personnel data, voluntary resignations and retirements accounted for about 90 percent of VHA's losses from the 5 shortage occupations annually from fiscal year 2011 through fiscal year 2015 (see figure 2). The percent of losses due to voluntary resignations from the 5 shortage occupations averaged 54 percent during this period, and retirements averaged 36 percent. However, for some occupations, voluntary resignations and retirements accounted for a smaller proportion of employee losses. For example, for physical therapists and psychologists, the resignation rate averaged about 44 percent and retirement averaged about 19 percent during the 5-year period. In these occupations, other reasons--primarily expiration of their appointments--averaged about 35 and 33 percent of losses, respectively. According to VHA officials, expirations of appointments occur when a nonpermanent, time-limited appointment ends due to the expiration of the work or the funds available for the position. For physical therapists and psychologists, the use of trainees, such as interns or post-doctoral fellows, accounted for the majority of losses due to expirations of appointments. Removals accounted for a small proportion (5 percent or less, on average) of losses in each of these 5 occupations. Voluntary resignations and retirements accounted for 84 percent of VHA's losses from the 10 occupations with the highest loss rates annually from fiscal year 2011 through fiscal year 2015. The percentage of losses due to voluntary resignations from these 10 occupations averaged about 55 percent during this period and retirements averaged 30 percent. The following summarizes the reasons for leaving VHA cited by exit survey respondents in the 5 shortage occupations: 28 percent said opportunities to advance and 21 percent said that dissatisfaction with certain aspects of the work, such as concerns about management and obstacles to getting the work done, was the primary reason they were leaving. Other than retirement, these were the most commonly cited reasons. 71 percent said that a single event generally did not cause them to think about leaving, while 28 percent reported that it did. 65 percent were generally satisfied with their jobs over the past year, while 25 percent reported that they were not. 50 percent indicated that they were generally satisfied with the quality of senior management, while 31 percent were not. 69 percent said that their supervisors did not try to change their minds about leaving, while 30 percent reported that they did. 73 percent felt that their immediate supervisors treated them fairly at work, while 15 percent reported that they did not. 67 percent felt that they were treated with respect at work, while 19 percent reported they were not. 50 percent reported that one or more benefits would have encouraged them to stay, such as alternative or part-time schedules (25 percent) or student loan repayment or tuition assistance (12 percent), among others. VHA's exit survey results were similar for respondents from the 10 occupations with the highest loss rates to those in the 5 shortage occupations. For example, respondents from these 10 occupations also said that advancement issues (34 percent) and dissatisfaction with certain aspects of the work (20 percent) were among their primary reasons for leaving. Additionally, the majority said that a single event generally did not cause them to think about leaving (71 percent) and about 47 percent reported that one or more benefits would have encouraged them to stay, such as an alternative or part-time schedule (22 percent) or student loan repayment or tuition assistance (12 percent), among others. We and others have highlighted the need for an adequate and qualified nurse workforce to provide quality and timely care to veterans. As we have previously reported, it is particularly difficult to recruit and retain nurses with advanced professional skills, knowledge, and experience, which is critical given veterans' needs for more complex specialized services. In our 2015 report--which included staff interviews at four medical centers--we found that VHA had multiple system-wide initiatives to recruit and retain its nurse workforce, but three of the four VA medical centers in our review faced challenges offering them. VHA identified a number of key initiatives it offered to help medical centers recruit and retain nurses, which focused primarily on providing (1) education and training, and (2) financial benefits and incentives. VA medical centers generally had discretion in offering these initiatives. The four medical centers in our review varied in the number of initiatives they offered, and three of these medical centers developed local recruitment and retention initiatives in addition to those offered by VHA. While three of the four medical centers reported VHA's initiatives improved their ability to recruit and retain nurses, they also reported challenges. The challenges included insufficient HR support for medical centers, competition with private sector medical facilities, a reduced pool of advanced training nurses in rural locations, and employee dissatisfaction. In our 2015 report we also found that VHA provided limited oversight of its key system-wide nurse recruitment and retention initiatives. Specifically, VHA conducted limited monitoring of medical centers' compliance with its initiatives. For example, in the past, VHA conducted site visits in response to a medical center reporting difficulty with implementation of one of its initiatives and to assess compliance with program policies, but VHA stopped conducting these visits. Consistent with federal internal control standards, monitoring should be ongoing and should identify performance gaps in a policy or procedure. With limited monitoring, VHA lacks assurance that its medical centers are complying with its nurse recruitment and retention initiatives, and that any problems are identified and resolved in a timely and appropriate manner. In addition, VHA has not evaluated the training resources provided to nurse recruiters at VA medical centers or the overall effectiveness of the initiatives in meeting its nurse recruitment and retention goals, or whether any changes are needed. Consistent with federal internal control standards, measuring performance tracks progress toward program goals and objectives and provides important information to make management decisions and resolve any problems or program weaknesses. For example, we found that VHA did not know whether medical centers had sufficient training to support nurse recruitment and retention initiatives. In particular, VHA did not provide face-to-face training specifically for nurse recruiters, but regular training was available to those assigned to a HR office as part of training available to all HR staff. Representatives from a national nursing organization reported that clinical nurse recruiters at VA medical centers often feel less prepared for the position than those assigned to HR offices, but VHA has not evaluated this disparity or its effects. Without evaluations of its collective system- wide initiatives, VHA is unable to determine how effectively the initiatives are meeting VHA policies and the provisions of the Veterans Access, Choice, and Accountability Act. Nor can VHA ultimately determine whether it has an adequate and qualified nurse workforce at its medical centers that is sufficient to meet veterans' health care needs. On January 23, 2017, the administration issued an across-the-board 90- day hiring freeze applicable to federal civilian employees in the executive branch. As of January 22, 2017, no existing vacant positions could be filled and no new positions could be created. The memorandum stated that the head of any executive department or agency may exempt from the hiring freeze positions that it deems necessary to meet national security or public safety responsibilities. In accordance with the memorandum, as of mid-March, VA has exempted 108 VHA occupations from the freeze because they were necessary to meet VA's public safety responsibilities. They included the 5 shortage occupations noted earlier (physician, registered nurse, physician assistant, psychologist, and physical therapist), as well as, for example, pharmacist, medical records technician, chaplain, and security guard. The recruitment and retention challenges VHA is experiencing with its clinical workforce are due, in part, to VHA's limited HR capacity, including (1) attrition among its HR employees and unmet staffing targets, and (2) weak HR-related internal control functions. Until VHA strengthens its HR capacity, it will not be positioned to effectively support its mission. In our December 2016 report on VHA's HR capacity, we found that attrition of HR staff grew from 7.8 percent (312 employees) at the end of fiscal year 2013 to 12.1 percent (536 employees) at the end of fiscal year 2015. In comparison, attrition for all VHA employees was generally consistent during the same period, from 8.4 percent in fiscal year 2013 to 9 percent at the end of fiscal year 2015 (see figure 3). Most of the turnover is due to transfers to other federal agencies, followed by resignations and voluntary retirement. In fiscal year 2015 HR specialists transferred to other federal agencies at a rate six times higher than all VHA employees. We found that between fiscal years 2011 and 2015, the majority of medical centers fell short of VHA's HR staffing goals, even with new hires to partially offset annual attrition (see figure 4). VHA established a target HR staffing ratio of 1 HR staff to 60 VHA employees to manage consistent, accurate, and timely delivery of HR services. However, in fiscal year 2015 about 83 percent (116 of 139) of medical centers did not meet this target. Of these 116 medical centers, about half had a staffing ratio of 1 HR staff to 80 VHA employees or worse. In other words, each HR employee at those medical centers was serving 20 to 80 more employees than recommended by VHA's target staffing ratio. According to the HR staff we interviewed, this has reduced HR employees' ability to keep pace with work demands and has led to such issues as delays in the hiring process, problems with addressing important clinical hiring initiatives, and an increased risk of personnel processing and coding errors. In addition, VHA's All Employee Survey results from 2015 indicate that HR staff reported feeling more burned out and less satisfied with their amount of work compared to the VHA-wide average in these areas. Specifically, about 48.1 percent of those who identified as HR specialists reported being satisfied with the amount of work compared to about 62.5 percent of employees VHA-wide. As noted above, as of mid-March 2017, VA has exempted 108 occupations from the current hiring freeze because VHA maintained they were necessary to meet VA's public safety responsibilities. However, the broad list of exemptions, ranging from physicians to housekeeping staff, did not include HR specialists, even though VHA ranked HR management as third on a list of mission critical occupations in its 2016 Workforce and Succession Strategic Plan. Given the attrition rate that we identified among HR specialists and the HR staffing shortfalls at many VA medical centers, a prolonged hiring freeze could further erode VHA's capacity to provide needed HR functions. In our 1982 report on hiring freezes under prior administrations, we concluded that government-wide freezes are not an effective means of controlling federal employment because they ignored individual agencies' missions, workload, and staffing requirements and could thus disrupt agency operations. We noted that improved workforce planning, rather than arbitrary across-the-board hiring freezes, is a more effective way to ensure that the level of personnel resources is consistent with program requirements. In our December 2016 report, we noted that weaknesses in HR-related internal control functions reduce VHA's ability to deliver HR services. Federal standards for internal controls require agencies to (1) establish an organizational structure that includes appropriate lines of accountability and authority, (2) evaluate the competencies of HR staff and ensure they have been appropriately trained to do their jobs, and (3) design information systems to meet operational needs and use valid and reliable data to support the agency's mission. We found shortfalls in each of these practices at VHA. Moreover, as shown in figure 5, the twin challenges of weak internal controls and limited HR capacity have had a compounding effect, creating an environment that undermines VHA's HR operations and impedes its ability to improve delivery of health care services to veterans. We reported that key areas for improvement include the following: Strengthen oversight of HR offices. VHA is structured so that the central HR offices at VA and VHA have inadequate oversight of medical center HR offices in order to hold them accountable. This lack of oversight contributes to issues with VHA's capacity to provide HR functions and limits VHA's ability to monitor HR improvement efforts and ensure that HR offices apply policies consistently. Our Standards for Internal Control requires an agency's organizational structure to provide a framework for planning, directing, and controlling operations to achieve agency objectives. VA and VHA's central HR offices are primarily responsible for developing HR policy, guidance, and training, while VISN and medical center HR offices are responsible for implementing HR policies and managing daily HR operations. However, as shown in figure 6, there is not a direct line of authority between the VISN and medical center HR offices and the central HR offices in VA and VHA. According to the director of VA's Office of Oversight and Effectiveness, the department's organizational structure enables medical center directors to effectively respond to the needs of veterans and other clients using available resources. However, VA and VHA HR officials with whom we spoke said that the organizational structure limits the department's ability to oversee individual HR offices, improve hiring processes, train HR staff, and implement consistent classification processes. Identify and address critical competency gaps. Federal standards for internal control require an agency to ensure that its workforce is competent to carry out assigned responsibilities in order to achieve the agency's mission. Additionally, our prior work has identified principles for human capital planning that recommend an agency identify skills gaps within its workforce, implement strategies to address these gaps, and monitor its progress. However, VA and VHA's model for assessing the competencies of HR staff is incomplete and fragmented. As one example, VHA's internal human capital reviews have consistently found that HR staff competencies are not being assessed and HR staff lack the necessary skills to deliver high-quality services. Further, although both VA and VHA provide a variety of training programs, HR staff with whom we spoke described barriers to completing them, including a lack of time to take training and train new hires, limited course offerings, and lengthy waiting lists for courses. Address long-standing information technology challenges. To have an effective internal control system, agencies should design their information systems to obtain and process information to meet operational needs. Likewise, our prior work on strategic human capital management notes that high-performing organizations leverage modern technology to automate and streamline personnel processes to meet customer needs. Data that are valid and reliable are critical to assessing an agency's workforce requirements. However, VA faces long-standing, significant information technology (IT) challenges that include outdated, inefficient IT systems and fragmented systems that are not interoperable. With respect to HR IT systems, in May 2016 we reported that VA's department-wide HR system, Personnel and Accounting Integrated Data (PAID), is one of the federal government's oldest IT systems and that VA is in the process of replacing it. As part of efforts to replace PAID, VA is developing and implementing an enterprise-wide, modern web-based system called HR Smart. VA officials told us that HR Smart will be implemented in phases across the department. According to agency documentation, HR Smart will enable HR staff to better manage information on employee benefits and compensation; electronically initiate, route, and receive approval for personnel actions; monitor workforce planning efforts and vacancies by medical center and across the department; and generate reports and queries. As VA continues to develop and implement its new HR system, VHA HR staff must rely on several separate enterprise-wide IT systems to handle core HR activities such as managing personnel actions and hiring and recruiting efforts. HR staff with whom we spoke stated that the amount of time they spent entering duplicate data into four or more non- interoperable systems and reconciling data between the systems has made their jobs more difficult and has taken time away from performing other critical HR duties. According to VA officials, once HR Smart is fully implemented, it should reduce HR offices' reliance on multiple HR systems and local tools and help to streamline HR processes. For example, according to program documentation, VA plans to implement functionality in HR Smart that will allow managers to initiate, review, and approve basic personnel actions independently. In these cases, HR staff would no longer be responsible for data entry. In conclusion, VHA's challenges recruiting and retaining clinical and HR employees are making it difficult for VHA to meet the health care needs of our nation's veterans. The prior reports on which this testimony is based made three recommendations to VA aimed at improving the oversight of nurse recruitment and retention initiatives and seven recommendations directed at strengthening VHA's HR capacity. Key recommendations included developing a process to help monitor medical centers' compliance with key nurse recruitment and retention initiatives and establishing clear lines of authority between VA and VHA's central personnel offices and those offices in individual medical centers to hold them accountable for improving HR functions. VA concurred with our recommendations and said they are taking steps to implement them. We will monitor VA's progress in addressing our recommendations and report the results of those efforts to Congress. Chairman Wenstrup, Ranking Member Brownley, and Members of the Subcommittee, this completes our prepared statement. We would be pleased to respond to any questions that you may have. If you have any questions on matters discussed in this statement, please contact Robert Goldenkoff at (202) 512-2757 or by e-mail at goldenkoffr@gao.gov, or Debra Draper at (202) 512-7114 or by email at draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Other key contributors to this testimony include Lori Achman, Assistant Director, Janina Austin, Assistant Director, Tom Gilbert, Assistant Director, Heather Collins, Analyst-in-Charge, Dewi Djunaidy, Sarah Harvey, Meredith Moles, Steven Putansu, Susan Sato, and Jennifer Stratton. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary:
VHA's ability to attract, hire, and retain top talent is critical to its mission to provide quality and timely care for our nation's veterans. GAO's prior work has found that VHA faces long-standing, systemic human capital challenges that limit its ability to improve delivery of health care services to veterans. This statement is based on GAO reports issued between September 2015 and December 2016 and discusses (1) the difficulties VHA is facing in recruiting and retaining staff for key clinical positions; and (2) VHA's capacity to perform key HR functions essential to addressing these difficulties. To conduct these studies, GAO reviewed VHA policies, directives, and other documents; analyzed VHA data; applied relevant federal internal control standards; and interviewed VA and VHA officials and staff in headquarters offices, as well as in eight VHA medical centers across the country. Challenges in recruiting and retaining both clinical and human resources (HR) employees along with weak HR-related internal control practices are undermining the Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) ability to meet the health care needs of veterans. In July 2016, GAO found that VHA losses in its 5 clinical occupations with the largest staffing shortages, including physicians, registered nurses, and psychologists, increased from about 5,900 employees in fiscal year 2011 to about 7,700 in fiscal year 2015. Voluntary resignations and retirements were the primary drivers. VHA's exit survey indicated that advancement issues or dissatisfaction with certain aspects of the work were commonly cited as the primary reasons people left. In September 2015, GAO found that VHA had multiple initiatives to recruit and retain its nurse workforce, but three of the four VA medical centers GAO reviewed faced challenges offering the initiatives due to, for example, a lack of sufficient HR support and competition with private sector medical facilities. GAO also found that VHA had not evaluated the training resources provided to nurse recruiters at VA medical centers. As a result, VHA is unable to determine to what extent its nurse recruitment and retention initiatives are effective and whether VHA has an adequate and qualified nurse workforce to meet veterans' health care needs. In December 2016, GAO found that VHA's limited HR capacity combined with weak internal control practices undermined VHA's HR operations and its ability to improve delivery of health care services to veterans. VA has exempted 108 clinical and administrative occupations from the recent hiring freeze; however, HR occupations are not among the exempt positions. A prolonged freeze could further erode VHA's capacity to provide HR services such as recruiting and hiring of staff who provide medical care to veterans. GAO previously made three recommendations to VA aimed at improving oversight of nurse recruitment and retention initiatives and seven recommendations directed at strengthening VHA's HR capacity. VA concurred with GAO's recommendations and is taking steps to implement them. GAO will monitor VA's progress.