RNs, along with other nursing support staff, provide care to patients on inpatient units at VAMCs. VA RNs are responsible for assessing and providing care to patients, administering medications, documenting patients’ medical conditions, analyzing test results, and operating medical equipment. To obtain an RN license, an individual must complete a nursing education program, meet state licensing requirements, and pass a nursing licensing examination. Several types of clinical and ancillary support staff assist RNs in caring for patients on inpatient units. Nursing support staff— such as licensed practical nurses (LPN) and nursing assistants (NA)— perform nursing duties such as recording patient vital signs and assisting with bathing, dressing, and personal hygiene. In addition, ancillary support staff perform housekeeping, patient transport, and food service duties. Clinical support staff—such as lab technicians—also assist RNs in their patient care duties, for example, by drawing and testing blood or performing electrocardiograms (EKG). Recognizing that developing and maintaining a strong cadre of RNs at VAMCs is vital to providing high quality of care to our nation’s veterans, the Congress and VA have both made efforts to better ensure that RN staffing levels at VAMCs are appropriate and to enhance recruiting and retention of RNs. These efforts include: To improve RN staffing, retention and job satisfaction, and patient outcomes, VA is actively encouraging its medical centers to take part in a nationwide program called the Magnet Recognition Program®. This program was developed by the American Nurses Credentialing Center (ANCC) to recognize health care organizations that provide nursing excellence and quality patient care. In order to attain Magnet™ status, hospitals must meet certain requirements, including requirements related to staffing practices and quality monitoring. Some research indicates that facilities that have attained Magnet™ status have better patient outcomes, significantly higher percentages of baccalaureate-prepared nurses, and higher nurse job satisfaction rates. As of 2008, three VAMCs have attained Magnet™ status, four VAMCs have completed the application process, and 22 VAMCs are in the process of applying for Magnet™ status. With respect to recruiting and hiring, VA has taken several actions. For example, in 2007, VA launched the VA Nursing Academy, a program designed to develop a pool of RN candidates for employment in VAMCs. Similarly, VA’s Learning Opportunities Residency program is designed to attract baccalaureate nursing students to work as RNs at VAMCs upon graduation. VA also has several other initiatives to enhance the educational preparation of its health care staff and scholarships for current employees pursuing degrees in nursing. These initiatives, which serve as recruitment and retention tools, include an education loan repayment program and scholarships for employees seeking health care careers. In August 2007, a VA Recruitment Process Redesign Workgroup made recommendations to redesign the recruiting and hiring of health care practitioners within VA, including RNs. The work group analyzed VA’s hiring process and identified barriers and delays in hiring. The work group’s findings and recommendations included a timeline for nurse hiring. As discussed later in this report, VA is in the process of implementing actions recommended by this work group. To enhance recruiting and retention of RNs at VAMCs, the Congress passed legislation in 2004 authorizing two alternate work schedules for RNs employed by the VA. One of these alternate schedules allows RNs to work three 12-hour shifts that are considered a 40-hour work week for pay and benefits purposes. The other alternate work schedule allows RNs to work full-time for 9 months with 3 months off duty within a fiscal year and be paid 75 percent of the full-time work rate for each pay period of that fiscal year. In addition to these alternate work schedules, executive branch government agencies—including the VA—are authorized by OPM to offer flexible work schedules. A flexible work schedule is an 80-hour biweekly basic work requirement that allows an employee to determine his or her own schedule—arrival and departure times—within the limits set by the agency. The standard work schedule for full-time VA employees is ten 8-hour work days within a 2-week period. VAMC nursing officials reported that although VA RNs are required to input patient data into VA’s PCS, many said they cannot rely on the information generated by PCS because the PCS is outdated and inaccurate. Because of the shortcomings of VA’s PCS, nurse managers use various other data to help set RN staffing levels for their inpatient units, such as historical staffing levels and benchmarking RN staffing levels to inpatient units in hospitals with similar characteristics. VA is proposing action to develop a new nurse staffing system but did not provide a detailed action plan and milestones for building and implementing such a system. VAMC nursing officials we interviewed told us that VA’s PCS does not generate reliable information that would allow them to better predict the RN staffing levels required for their inpatient units. These nursing officials cited two key limitations of this information—it is outdated and inaccurate. VA headquarters officials in the Office of Nursing Services (ONS) and VA’s OIG also reported that PCS has significant limitations. In 2004, VA’s OIG also recommended that VA develop a new standardized nurse staffing methodology capable of accurate staffing estimates and VA concurred with the OIG’s recommendation. According to nursing officials we interviewed, VA’s PCS was developed in the 1980’s based on time and motion studies of RNs conducted over 20 years ago; as a result, the information the system produces does not account for all the tasks currently performed by RNs on inpatient units. For example, VA’s PCS does not account for certain recent RN tasks—such as the administration of certain intravenous medications or monitoring of a patient’s abnormal heart activity—that were once limited largely to intensive care units that cater to sicker patients but are now performed on other inpatient units. Similarly, VA’s PCS generates estimates that do not reflect tasks associated with VA’s computerized bar code medication administration (BCMA) system that was fully implemented in 2003, more than a decade after the development of VA’s PCS. These RN tasks include tracking, monitoring, and reporting medication administration performed using the BCMA on an inpatient unit. VAMC nursing officials also told us that VA’s PCS produces inaccurate data with respect to patient acuity levels, which in turn can generate erroneous HPPD estimates. Specifically, a key piece of data VA nurses enter into the VA PCS is the acuity level for each patient on an inpatient unit. To do this, RNs use one of five PCS categories, with category 1 representing patients requiring the lowest level of care and category 5 the highest level of care. Nursing officials we interviewed at VAMCs we visited and officials with VA’s ONS reported that VA’s PCS does not accurately capture the actual acuity level of patients on inpatient units According to VAMC nursing officials we interviewed, nursing staff at VAMCs are required to classify patients by acuity level on a daily basis using VA’s PCS. However, nursing officials reported that classifying patients by acuity level using the PCS is not a productive use of their time because the information output from the PCS is not useful for RN staffing purposes. In addition, officials with the VA OIG and ONS told us that the information contained in VA’s Computerized Patient Record System (CPRS)—concerning a patient’s illness, medical condition, and treatments—is not integrated with, or available within VA’s PCS when nurses assess and assign patients to one of the five acuity levels. VA’s ONS is proposing to convene an interdisciplinary team—consisting of headquarters and field staff—to develop a more effective RN staffing system for VA by 2012, according to VA’s Chief of Nursing Services. The Chief told us that the new RN staffing system will include a database that reflects up-to-date nursing tasks as well as information from patients’ computerized medical records, and that this database will also be used to evaluate the effectiveness of nursing care at VAMCs. The Chief also reported that as part of the new RN staffing system, VA may upgrade or replace its PCS. In developing a new or upgraded PCS, VA needs to ensure that all current nursing tasks and patient acuity are accurately captured. However, ONS did not provide a VA charter for the interdisciplinary team or a detailed action plan with specific timelines for the building, testing, and implementation of an updated system for staffing RNs on inpatient units in its VAMCs. Instead of relying on the information generated by VA’s PCS, VAMCs use various other data to determine RN staffing for inpatient units. Our survey of nurse executives coupled with our visits to VAMCs provides insights into the types of data used and shows that information used for staffing RNs varies considerably among VAMCs. Results from the survey show that nurse managers typically consider a combination of data to estimate both the number of RNs and the RN skill levels their inpatient units require. The survey results also show that the types of data most commonly used by inpatient unit nurse managers across VAMCs are the average number of patients typically cared for on the unit, HPPDs, the acuity level of patients on the unit, the number of RN staff historically assigned to the unit, and the ratio of RNs to patients on the unit. Nurse managers at the eight VAMCs we visited told us how they use various data to help set RN staffing levels for their inpatient units. At four VAMCs we visited, nurse managers told us that they set RN staffing levels for their inpatient units by adhering to the historical staffing levels that had been established for the units.