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.