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Hearing Transcript on Human Resources Challenges with the Veterans Health Administration.
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HUMAN RESOURCES CHALLENGES WITH THE VETERANS HEALTH ADMINISTRATION
HEARING BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS SECOND SESSION MAY 22, 2008 SERIAL No. 110-88 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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Malcom A. Shorter, Staff Director SUBCOMMITTEE ON HEALTH
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined. |
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C O N T E N T S
May 22, 2008
Human Resources Challenges with the Veterans Health Administration
OPENING STATEMENTS
Chairman Michael Michaud
Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member
Prepared statement of Congressman Miller
Hon. Phil Hare
WITNESSES
U.S. Department of Veterans Affairs, Joleen Clark, Chief Officer, Workforce Management and Consulting, Veterans Health Administration
Prepared statement Ms. Clark
American Association of Nurse Anesthetists, Angela Mund, CRNA, MS, Clinical Director, University of Minnesota Nurse Anesthesia Area of Study, Minneapolis Veterans Affairs Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs
Prepared statement of Ms. Mund
American Federation of Government Employees, AFL-CIO, J. David Cox, RN, National Secretary-Treasurer
Prepared statement Mr. Cox
American Psychological Association, Randy Phelps, Ph.D., Deputy Executive Director for Professional Practice
Prepared statement of Dr. Phelps
Disabled American Veterans, Adrian M. Atizado, Assistant National Legislative Director
Prepared statement of Mr. Atizado
Paralyzed Veterans of America, Fred Cowell, Senior Associate Director for Health Analysis
Prepared statement of Mr. Cowell
Nurses Organization of Veterans Affairs, Cecilia McVey, BSN, MHA, RN, Immediate Past President, and Associate Director for Patient Care/Nursing, Veterans Affairs Boston Healthcare System, Veterans Health Administration, U.S. Department of Veterans Affairs
Prepared statement of Ms. McVey
Vertical Alliance Group, Inc., Texarkana, TX, Jay W. Wommack, Founder, President and Chief Executive Officer
Prepared statement of Mr. Wommack
MATERIAL SUBMITTED FOR THE RECORD
Post Hearing Questions and Responses for the Record:
HUMAN RESOURCES CHALLENGES WITH THE VETERANS HEALTH ADMINISTRATION
Thursday, May 22, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Snyder, Hare, and Miller.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. MICHAUD. The hearing will come to order, and I will ask the first panel to come forward.
I would like to thank everyone for coming today.
The Veterans Health Administration's (VHA's) mission is to provide patient-centered healthcare that is comparable to or better than care available in the non-U.S. Department of Veterans Affairs (VA) sector. To do this, VHA must have a viable healthcare workforce that is competent, well-trained and happy.
Over the past 5 years, the VA has built a reputation of delivering healthcare efficiently and effectively. VA has been touted as the "best care anywhere," and the Department has been recognized on numerous occasions for healthcare quality and patient satisfaction.
However, in order to carry that banner forward, careful planning and efficient processes must be put into the system to ensure continued success.
We know that VA's workforce is aging, with an average age of 48.6 years. We know that at the end of 2012 a significant percentage of the employees will be eligible to retire.
This Subcommittee has held many hearings that have examined the appropriateness and quality of care and treatment that veterans receive within the healthcare system. This hearing today will focus on the human resource challenges that VHA must address in order to ensure that there will not be a gap in expertise and quality of care provided to our veterans.
The Subcommittee realizes that this is a complex issue, but we also recognize that it is an important one that deserves serious thought and consideration as well.
I would like to recognize Mr. Miller for any opening statement that he might have.
[The statement of Chairman Michaud appears in the Appendix.]
OPENING STATEMENT OF HON. JEFF MILLER
Mr. MILLER. Thank you very much, Mr. Chairman. I do appreciate you holding this hearing today to examine all those challenges the VA faces in regards to keeping the high-quality healthcare workers that are currently in the system. They are on the front line of the healthcare issue every single day.
Our servicemembers who have honorably served our country deserve high-quality healthcare, and we must do what we can to keep those professionals retained and recruit them as well. One of the most pressing problems we face as a Nation is a marked shortage in virtually all areas of the healthcare worker industry, including nurses, physicians, physicians' assistants, psychologists, pharmacists, and physical and occupational therapists.
The VA system has been recognized for the significant benefit of its use of electronic medical records and focus on preventative care. To make sure that our veterans continue to receive the best care, it is critical that we see the VA as a workplace of choice. So I appreciate you putting this hearing together to focus and see what we can do better.
I yield back the balance of my time.
[The statement of Congressman Miller appears in the Appendix.]
Mr. MICHAUD. Thank you.
Mr. Hare?
OPENING STATEMENT OF HON. PHIL HARE
Mr. HARE. Thank you, Mr. Chairman. I want to thank you and Ranking Member Miller for holding this hearing today.
The Veterans Health Administration is one of the most impressive healthcare delivery systems in the entire world, and that is in large part due to the dedicated medical professionals who make up the system. From doctors to nurses to technicians to psychologists, these are the men and women who are on the ground every day taking care of our Nation's veterans.
The veterans population will undergo significant changes over the next two decades. And as such, the leadership at the VHA will have to be prepared to handle these challenges.
One of the biggest challenges is the recruitment and retention of highly qualified medical personnel at a time when the overall health industry is facing massive shortages. The VA must be able to compete with the private sector for medical staff. And we must ensure that, as the VHA continues forward, that they have the tools and the funds necessary to guarantee adequate numbers of staff in order to continue the care of our veterans.
Once again, Mr. Chairman, I want to thank you for holding the hearing today. I look forward to hearing from our panels. And thank you very much, Mr. Chairman. I yield back.
Mr. MICHAUD. Thank you very much, Mr. Hare.
Our first panel includes David Cox, a Registered Nurse (RN) who is the National Secretary-Treasurer for American Federation of Government Employees (AFGE) of the AFL-CIO.
I want to welcome you, David, here this morning.
And Dr. Randy Phelps, who is the Deputy Executive Director of the American Psychological Association (APA); and Angela Mund, who is a CRNA, the Clinical Director for Minneapolis VA Medical Center, who is here on behalf of the American Association of Nurse Anesthetists (AANA); and then Jay Wommack, President of Vertical Alliance Group, Inc.
So I want to welcome our four panelists this morning and am looking forward to hearing your testimony.
We will start off with Mr. Cox.
STATEMENTS OF J. DAVID COX, RN, NATIONAL SECRETARY-TREASURER, AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO; RANDY PHELPS, PH.D., DEPUTY EXECUTIVE DIRECTOR FOR PROFESSIONAL PRACTICE, AMERICAN PSYCHOLOGICAL ASSOCIATION; ANGELA MUND, CRNA, MS, CLINICAL DIRECTOR, UNIVERSITY OF MINNESOTA NURSE ANESTHESIA AREA OF STUDY, MINNEAPOLIS VETERANS AFFAIRS MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION U.S. DEPARTMENT OF VETERANS AFFAIRS, ON BEHALF OF AMERICAN ASSOCIATION OF NURSE ANESTHETISTS; AND JAY W. WOMMACK, FOUNDER, PRESIDENT AND CHIEF EXECUTIVE OFFICER, VERTICAL ALLIANCE GROUP, INC., TEXARKANA, TX
Mr. COX. Chairman Michaud and Ranking Member Miller and distinguished Members of the Subcommittee—it seems like I am getting off to a bad start here. I am tying my tongue up this morning. I have never been first on a panel; maybe that is what it is. Thank you for the opportunity to testify today. AFGE greatly appreciates the Subcommittee's continued attention to the impact of VA healthcare workforce problems on patient care.
Veterans want to get their care from the VA because VA healthcare professionals are extremely dedicated to their patients and committed to the mission of the VA. In the 1980s, labor management collaboration helped transform the VA into a healthcare leader in best practices, patient safety and healthcare information technology.
AFGE believes the greatest human resources challenge facing VHA today is the continuing erosion of title 38 collective bargaining rights, as I will discuss shortly. First, I would like to address several other human resources issues of concern to AFGE.
The hybrid title 38 process, which covers psychologists, social workers, pharmacists and licensed practical nurses (LPNs), among others, has become severely backlogged. It is also troubling that VHA employees lose their veterans' preference when they are converted to title 38 from title 5.
Therefore, AFGE urges this Subcommittee to reject proposals to add more positions to title 38 and instead conduct a pilot project using a streamlined title 5 hiring process to compare the two systems. We would be pleased to work with you to develop this pilot project and believe it can provide valuable lessons for other Federal employers.
AFGE also urges the Subcommittee to conduct oversight into the many implementation problems surrounding the 2004 physician pay law, such as secretive process for setting market pay and use of improper performance measures. Since Congress is still waiting for the VA's long-overdue report on how well the pay law is working and whether it is has reduced the VA's reliance on costly contract physicians, we urge the Subcommittee to conduct its own study on this important law instead.
Nurse alternative work schedules provide full-time pay for working 3 12-hour days per week or 9 months per year. These schedules are very popular in the private sector and could be a valuable VHA recruitment and retention tool. Unfortunately, VHA refuses to offer this schedule option to its nurses, even though they were given this authority by Congress 4 years ago. AFGE recommends that Congress amend the law to require the VA to offer alternate work schedules based on a fixed formula that aligns facilities with their local labor markets.
Turning to title 38 collective bargaining rights, we are very grateful to Chairman Michaud and Subcommittee Members Berkley, Brown and Doyle for cosponsoring H.R. 4089. This bill is an essential enforcement tool for past and future VHA recruitment and retention legislation.
In 1991, Congress provided RNs, physicians and other pure title 38 providers with rights to challenge improper personnel policies through grievances, arbitrations and the court. Providers lost these rights because the VA began using an arbitrary interpretation of the three exceptions in section 7422 of title 38: professional conduct and competency, peer review, and compensation.
Management's section 7422 policy directly contradicts Congressional intent, as is evident by the plain language of the law and the legislative history. Management's section 7422 policy is also inconsistent with its own position that it took in 1996 with a labor management agreement to allow grievances over indirect patient care matters, scheduling, and rights to pay survey data.
The VA contends that amending section 7422 will allow labor to disrupt patient care. But management's rights to determine the agency's mission under title 5 already protect against that. And the VA cannot point to a single case where a grievance involved a challenge to medical procedures. VHA employees who have full grievance rights, such as LPNs, psychologists, and pharmacists, never use these rights to disrupt patient care.
The VA also contends that current law gives title 38 providers fair process for deciding when a grievance can be filed, pointing to a review by the Under Secretary for Health. We asked, fair to whom? In the past 3 years, 100 percent of these decisions have been in favor of management. Shouldn't VA healthcare dollars be spent on caring for veterans, not looking for ways to block legitimate concerns of hard-working, dedicated nurses and physicians?
Thank you, Mr. Chairman. I would be glad to entertain any questions from the Committee.
[The statement of Mr. Cox appears in the Appendix.]
Mr. MICHAUD. Thank you very much.
Doctor?
STATEMENT OF RANDY PHELPS, PH.D.
Dr. PHELPS. Thank you, Mr. Chairman, Ranking Member Miller and distinguished Members of the Subcommittee. I am Dr. Randy Phelps, Deputy Executive Director for Professional Practice of the American Psychological Association.
We are the largest association of psychologists, with approximately 90,000 full doctoral psychology members and another 50,000 graduate students in the pipeline. Our folks are engaged in the study, research and practice of psychology.
I am currently a licensed clinical psychologist but formerly a practitioner myself, a clinical researcher and educator. And for the last 15 years, I have been on the APA Executive Staff and have served as APA's liaison to Professional Psychology in the Department of Veterans Affairs.
We really appreciate the opportunity to testify today about human resources challenges within VHA.
I should note at the outset that VHA is the workplace of choice for many of our members. There are over 2,400 psychologists working nationwide in the system. And, in fact, VA is the largest single employer of psychologists in this country.
Professional psychology was born as a result of the needs of returning soldiers from previous wars, particularly World War II. So we owe a great debt to the brave men and women who have served this country.
I will shorten the remarks, obviously, for the oral testimony. There is considerable amount of detail in the written testimony.
But psychologists are very actively involved, particularly in the mental health side, of treatment of veterans in VA. The architects of the two evidence-based practice treatments for post traumatic stress disorder (PTSD) are psychologists. Psychologists are serving a very critical role in understanding diagnosis and treatment of traumatic brain injury (TBI), which is the other signature wound of the war, alongside nursing, neurologists and other folks.
Recruitment of psychologists in the VA is actually in a good place at this point. It has not been until the last year and a half. And we applaud VHA's efforts to add 800 new positions for doctoral psychologists since 2005, bringing us up to that 2,400 psychologists in the system. Most of those folks, I should add, are young psychologists entering the system at GS-11.
I should emphasize that every psychologist who comes out of a clinical or counseling program already knows how to treat PTSD, depression and so forth.
The thing that I wanted to emphasize, though, about recruitment is that the staffing levels are a very recent developments. It was only two years ago where we reached the staffing levels of psychologists in the VA of the 1995 years. So the curve has been going down until just very recently with the hiring of this new cadre of psychologists.
Additionally—and this gets to the issue of retention that I would like to spend a little bit more time on—additionally, the number of GS-14 and GS-15 psychologists in the system at the higher leadership levels are actually not increasing similarly. The GS-15 level is lower than it was in 1995.
The VA has done a good job of recruiting new psychologists coming into the system because it is hiring its own. We have approximately 600 psychology training positions within VA, and 75 percent of the new hires are past VA psychology trainees.
There are three major problems, however, that affect retention of the workforce that I can elaborate on later if you have questions.
One is a lack of uniform psychology leadership positions. We are the only mental health position without an officially designated leader at medical centers. There is a very inequitable access to key leadership positions throughout VA. And there are, as you have heard some from a colleague, very serious implementation issues with the hybrid title 38. In fact, I would describe the implementation of the hybrid title 38 system as an absolute boondoggle, bureaucratically and otherwise, for the system.
These problems—which, again, we can elaborate on later—have led to a number of very chilling situations for psychologists throughout the country, where folks are leaving the VA to go to the private sector, losing their positions, inability to get advancement and so forth.
And we consider those kinds of problems as the most serious obstacles to making VA the workplace of choice for psychologists now and in the future, because without clear advancement systems in place, VA faces critical long-term recruitment and retention problems. As psychologists come to believe that there is little possibility for advancement in the system, regardless of the level of complexity of their responsibilities, fewer VA psychologists will be willing to accept positions of greater responsibility.
And, in addition, high-potential trainees coming into the system the VA would like to recruit for the future will increasingly, and are increasingly, seeing VA as a dead-end for their careers and will be attracted to other career options with more potential for advancement.
And we thank you very much for this opportunity to testify today. Thank you.
[The statement of Dr. Phelps appears in the Appendix.]
Mr. MICHAUD. Thank you.
Ms. Mund?
STATEMENT OF ANGELA MUND, CRNA, MS
Ms. MUND. Chairman Michaud, Ranking Member Miller and Members of the Subcommittee, good morning. My name is Angela Mund. I am a Certified Registered Nurse Anesthetist, or a CRNA, at the Minneapolis VA. I also serve as President of the Association of VA Nurse Anesthetists. And I am pleased to appear before you on behalf of my profession, the American Association of Nurse Anesthetists and its 39,000 members in the United States.
You have my written statement, and I ask unanimous consent for it to be entered into the record.
Mr. MICHAUD. Without objection.
Ms. MUND. America's CRNAs provide some 30 million anesthetics annually in every healthcare setting requiring anesthesia care, and we provide that safely. The Institute of Medicine reported in 2000 that anesthesia is 50 times safer now that in was in the 1980s. For over 125 years, nurse anesthetists have met the mission of caring for our veterans, caring for those who have borne the battle, their widows and orphans.
Nurse anesthetists are the predominant provider of anesthesia services in the VA and are the sole anesthesia provider in 12 percent of VA facilities. In the days prior before I left for this hearing, I personally provided anesthesia for our veterans. Any of the more than 500 CRNAs in the Veterans Health Administration could say the same.
But the average VA CRNA is 53 years old, 7 years older than the profession's average, and is approaching retirement. In any recent year, nearly one in five VA CRNAs leaves or retires from the VA. Twenty-four VA facilities report CRNA vacancies. We believe that actual number is closer to 40, and the U.S. Government Accountability Office (GAO), in their report, used 70 as the number. Contract personnel also fill about 150 of the VA CRNA posts.
We are increasingly concerned that without a sufficient number of CRNAs in the VA system, our veterans won't get the care they need and deserve. They may have to wait too long for that care, which ultimately may increase cost to the U.S. Treasury.
A report last December from the GAO confirmed what we, in the VA, have long known. The GAO found 54 percent of VA facilities have had to close operating rooms, and 74 percent have had to delay surgeries for lack of CRNAs. Twenty-six percent of VA CRNAs plan to retire within the next 5 years, and the agency has struggled to both recruit and retain nurse anesthetists. Seventy-four percent of VA respondents to the GAO survey said they had difficulty recruiting CRNAs.
The VA's struggle has not been for lack of CRNAs in the marketplace. In 2007, accredited nurse anesthesia educational programs produced over 2,000 graduates, an 88 percent increase in just 5 years, in order to meet the growing demand for anesthesia services. Rather, the GAO found, and we agree, that the VA CRNA compensation is far below market levels in many localities.
The issue of below-market compensation was cited by 90 percent of chief anesthesiologists reporting difficulty recruiting CRNAs and by 77 percent of chief anesthesiologists reporting difficulty retaining CRNAs. In some facilities, bad working conditions also sent good CRNAs elsewhere.
We have three recommendations to close this gap and to ensure American veterans have the necessary anesthesia care for the surgical and invasive diagnostic procedures they require.
First is to enhance the VA relationship with the nurse anesthesia educational programs. Already some 70 VA hospitals serve as clinical practice education sites for nurse anesthesia schools. Many hospitals find serving these clinical practice sites helps them recruit new CRNAs.
Second is to continue nurturing the VA's joint relationship with the U.S. Army Nurse anesthesia educational program at Fort Sam Houston, Texas, which educates CRNAs for VA service. The current program uses the VA Employee Incentive Scholarship Program, or EISP, to fund tuition, fees and salary reimbursement for nurse anesthesia students who then fulfill a service commitment to the VA.
Third is to bring VA's CRNA compensation closer to local market rates. The GAO recommends VA facilities take advantage of VA locality pay policies. But that will not be enough to close the gap. In addition, Congress should act to lift the statutory cap on VA CRNA pay so that local facilities can set compensation at rates closer to market levels.
Of all the options available to close the VA's CRNA workforce gap and ensure veterans gets the high quality of care they deserve, these three suggestions are the most cost-effective and the easiest to carry out.
Thank you, and I would be happy to take your questions.
[The statement of Ms. Mund appears in the Appendix.]
Mr. MICHAUD. Thank you very much.
Mr. Wommack?
Mr. WOMMACK. I would like to start with a quote. "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists"—Eric Hoffer.
I don't need to repeat the nursing shortage; everybody up here knows that. The baby boomers are about to retire. We, two years ago, entered the first baby boomer turning age 60. This year, the first baby boomer started to retire at 62. And this generation looks like a basketball going through the belly of a snake, and behind it we do not have enough people to fill the needs in the healthcare industry.
On top of that, we have a declining dollar. A declining dollar causes devaluation of the currency, which means the Canadian dollar is more powerful. We are seeing nurses leave the United States, to go back up north.
We see all these things and we see the nursing shortage is in quite a state, but I think there is a worse shortage than that out there, and the worst shortage is the shortage of qualified, well-trained, recruiting personnel, not just to recruit nurses and medical personnel, but also to go out and actively recruit people to teach in the schools, because we are short on educators. We had to turn down 38,000-plus, in the last few years, going to schools to learn how to be medical personnel.
Each month, millions of dollars are spent on advertising to draw people into not just the private sector, but into the public sector, both sectors, to draw them into the medical community, to recruit them for institutions. Millions of dollars are spent to generate leads and phone calls. And guess what happens? We have dealt with the private sector, and 82 percent of the phone calls for people that would like to have jobs go unanswered. I cannot speak for the VA system; I haven't worked with them. But in the private sector, that is an astounding number, and that number is shocking.
Mr. Chairman, Members of Subcommittee, my name is Jay Wommack. I am the Chief Executive Officer of a company called Vertical Alliance Group. We are an Internet-based training, recruiting company. We were founded in 1999. We have 80 Web sites, sub-domains and domains, of which a couple of them represent the medical community, one called NurseUniverse, one called MedVotech. Obviously, the names imply they are out to recruit nurses and people for the medical vo-tech schools. We operate those Web sites.
And I have to tell you, I am honored to be here to make this presentation. It is a wonderful experience and wonderful opportunity, and I appreciate you all taking the time to hear us and our testimony.
I don't make any claim to be a professional in the healthcare services area. However, we do know quite a bit. In the last 9 years, we have developed quite a bit about the process of recruiting and retaining good employees. Now, we do this with boot camps. And let me address that issue real quick.
There is a dire lack of training for people that know how to go out and deal with the society today. The Internet changed everything. It made us an immediate-gratification society. Things happen fast. I mean, when I go to Amazon and I go and order a book, I want it, I want it now. I don't like waiting till tomorrow. And this is how people are when they are looking for jobs. They go fill out an application or make a phone call. These people are hanging up before one minute when no one is answering the telephone. They are sending in applications, and you have seen the medical applications. It takes time to fill out an application. They send those in, and they get no response.
So what we did as a company is we started to develop processes that basically said we are going to train people from being paper processors, the old style of human resource, into active, proactive salespeople. Because that is what it takes to compete in this environment.
We train them to be salespeople through our boot camps. We empower people and teach the salespeople—we call them salespeople—we teach them sales training. We teach them direct-response marketing. We teach them what it costs to actually recruit a nurse. Many people don't know. Advertising cost per hire is $10,000 to recruit a nurse, according to AMA. It costs between $35,000 and $70,000 to recruit a nurse, not to mention a nurse anesthetist. So we are training these people, we are empowering them, teaching them what it takes to go out and be a proactive recruiter.
Have we had success? The standard average of a recruiting department gets between 1 and 2 percent closing on the people that apply for a job. Our companies, on a bell curve, at the top of it, get an average of 12 percent closing. Some, obviously, have gotten much more than that, some less, but on the average, on the bell curve. That is significant savings to the bottom line. The process lends itself to the lowest cost per hire.
But you have to inspect what you train, and you have to continue to teach what you train. So we developed a process, an online, Internet, databased program that basically teaches, tracks, trains and follows up on all the education we provide at the boot camps. We do it daily, weekly, monthly. It is available 24/7.
It doesn't just happen, though. In order for a program to be successful, it must have buy-in from the top. Obviously, we wouldn't be sitting here if there wasn't buy-in from the top.
I visit with a number of VA healthcare facilities. The executives at those facilities, they absolutely care. They would like to push forward, and they have put together great programs, but they like to push forward and get their hiring in order.
I am excited to be here. I appreciate the opportunity to speak, and I will be glad to answer any questions.
[The statement of Mr. Wommack appears in the Appendix.]
Mr. MICHAUD. Thank you very much. I appreciate it.
My first question will be for Mr. Cox.
You talked about H.R. 4089, the bill that is pending. If that is passed, what impact will that really have on recruitment and retention, in your opinion?
Mr. COX. We believe that it would give the registered nurses and physicians the same rights that other employees have in the VA; that if there are workplace disputes, that they would have an avenue to resolve those disputes and to seek relief in that arena.
It is a message we hear from our membership and the VA employees over and over, and we believe that it would certainly make for a better workplace.
Mr. MICHAUD. But as far as the recruitment or retention, do you think it will have a positive effect?
Mr. COX. I think it will definitely have a positive effect on the recruitment and retention, because, again, when you are able to resolve problems in the workplace through a negotiated agreement to resolve those issues, that makes people feel better. There is a way to seek relief if you believe things are wrong.
I believe, also, the fact that the pay data, that we have all the locality pay systems, but now if a request is made to the VA, "Share this data with us, show us what you are paying, give us information," it is, "No, we do not have to provide that to you, because that is a section 7422 issue." I believe it would bring more light to the issue of pay and the recruitment process. But it would definitely be a positive impact.
Mr. MICHAUD. Thank you.
Dr. Phelps, you had mentioned the impact of the hybrid title 38. What impact would moving psychologists to title 38 from the hybrid title 38 have on recruitment and retention of these professionals?
Dr. PHELPS. Mr. Chairman, that is an issue that we are—because we are so frustrated with the difficulties and the implementation problems with the hybrid system, that is an issue that we are looking at very seriously right now.
Preliminarily, we think it would be the way to go for psychologists. We are the only doctoral-level professionals in the VA system that are not in the title 38 system. So we are very much in favor of that direction.
Mr. MICHAUD. Thank you.
Ms. Mund, how many CRNA candidates rotate through the 70 VA training sites annually?
And my second question is, out of that, how many of those candidates actually choose the VA upon completion of their training?
Ms. MUND. I don't have those numbers with me, but I can have my staff look at that.
However, what I can speak to is—I am clinical director of a nurse anesthesia program through the University of Minnesota. And the VA in Minneapolis is our primary clinical site. We have had a relationship with them 25 years, I believe, recently. And we send 10 students per year through the VA. We get some support from Central Office, which we appreciate. In previous years, as much as 75 percent of the graduating class have stayed at the VA. However, in the last 2 years, we have had one person out of 20.
And a lot of that is due to low pay, is the main thing. I mean, they come out with student loans and are unable to have a salary that makes it easier to pay those student loans off.
And the other big piece of it is the employee debt-reduction program that the VA has, it is not entirely, through issues with human resources, lack of understanding of the program. Not everybody who has been eligible has been able to take advantage of that as a student loan payback. So they have chosen to go to places where they can see exactly, when they apply, HR can tell them, "This is what you will make, this is what we will give you, and this is what your loan payback is." The VA is a little bit hazy on that, so students elect to go elsewhere.
Mr. MICHAUD. I believe it was in your written testimony, you recommended $400,000 in fiscal year 2009 appropriations to expand the joint education program. How many additional CRNAs would this funding affect?
Ms. MUND. What they have right now is they have had seven graduates and are working. They have three who are in what we call phase II, which a clinical portion, three that are in the first-year portion, and three that are starting.
I believe that they would like to increase that number, and the Army is available with slots, with seats for those, but they need additional funding to have the students come.
The benefit of going there is that you get your tuition, salary and your education paid for. And then they have a three-year commitment after completing the program.
Mr. MICHAUD. Thank you.
My last question is for Mr. Wommack.
What immediate action should the VA take to modernize their hiring system so that it is competitive with the private sector?
Mr. WOMMACK. That is a very good question.
The first thing I would do is I would start training the personnel on being very proactive. You have to train these people. They have the tools in place. The VA has done a great job of putting together a package of information, kits like that. But they have to be brought into the 21st century via the technology, the platforms of technology that they have at their disposal and that we offer.
They have to be trained, and they have to be trained in the value of what they are doing, the lead. The half-life of a lead, when someone picks up that phone to call or when someone sends in an application, the half-life of that lead is probably less than 4 hours. In other words, if you don't touch it in 4 hours, they are gone. That is what we found; it may be even shorter than that.
So the first thing I would do is set up training for them. And then you have to follow up and monitor exactly what you have taught. You have to inspect it every single week. We do that with our existing clients. We train them, and then we follow up every single week, and we make them respond to us, because that is where you ferret out what the real problems are. You find out what is working, what is not working, and then you adjust it and you change it. And then you continue the education process.
Mr. MICHAUD. Great. Thank you.
Mr. Miller?
Mr. MILLER. Thank you, Mr. Chairman.
Mr. Cox, can you give me a little feel for the difference between title 5 and title 38 in regards to the hiring process? How would title 5 be more or less stringent than title 38?
Mr. COX. Title 5 employees get on registers. They go through, as you know, the various places throughout the country. They apply with USAJOBS, those type things. They get on registries. They are hired. From that, they get veterans' preference, things of that nature.
Title 38, like registered nurses and physicians, they can go to a VA medical center, fill out an application and be hired. There is a boarding process that title 38s have to go through, the credentialing process, things of that nature, which takes a very lengthy period of time. And that is what really holds up a lot of the hiring process at the VA in the title 38 arena.
With the hybrid title 38s, again, the VA has not developed a lot of the qualification standards, so there is not the boarding processes to promote these people and to move them through the proper grades. It is a very, very complex hiring system.
Mr. MILLER. Well, you recommended establishing a pilot program streamlining title 5. I would like to know a little more in detail about, what that plan would—or how it would differ from the current title 5? Wouldn't it be just as useful to streamline or do a pilot program to streamline the hybrid title 38 hiring process?
Mr. COX. We believe that you can go to Office of Personnel Management (OPM) and the agency, VA, can work with OPM, do a demonstration project to—like, nursing assistants is one group that, if people are certified, that you could hire them through a title 5 process that would actually be easier than the hybrid title 38. Because with that, you have to develop the qualification standards, the boards that would then have to evaluate the people, determine their promotions and appointments and things of that nature.
So we believe that there are procedures with OPM that could actually streamline title 5 and make it easier than hybrid title 38. And one thing that we believe that that would also help, it would maintain the veteran preference for the employees.
Mr. MILLER. Give me a little indication of how the retirement benefits differ from the Federal worker and the private sector right now.
Mr. COX. The difference in the retirement benefits?
Mr. MILLER. Yes.
Mr. COX. I am not sure that I could give you a total picture on that.
Mr. MILLER. More, less, better, worse?
Mr. COX. I retired from the Federal Government myself 2 years ago, and I have friends that are in the private sector. And I would say, with the current FERS employees, it is about comparable to the private sector. Most employees in the private sector have some type of matching 401(k) plan and some other defined benefit plan, such as—available with that. But I would say this were fairly comparable in that arena.
And, in some areas, I believe the private-sector retirement may be better; in others, obviously, the Federal Government. I am not sure that I am—
Mr. MILLER. What about health insurance?
Mr. COX. Health insurance, private sector, in many cases, is better than the Federal employee health insurance.
Mr. MILLER. Dr. Phelps, what benefits do you see in bringing psychologists fully into the title 38 program?
Dr. PHELPS. As I said, Mr. Miller, we are looking more closely at that. We have tried to be good citizens with the hybrid system. So the benefits would be to eliminate some of these kinds of problems with the hybrid system.
Let me give you a couple of examples. As Mr. Cox said, that with the hybrid title38 system there is required the creation of professional standards boards for each of those disciplines. Psychology has a national professional standards board, and it also has developed its quality standards. And so that process is under way.
But what has been happening for the last year or so is that psychologists with additional scope of responsibility—running huge treatment programs, 60 psychology staff under them and so forth—who have submitted to the professional standard boards and have then been recommended nationally for a grade increase have then been stymied at the level of the local medical center, in most cases. Some cases, it is at division level.
And the VA itself is issuing, in some cases certainly, informational missteps about who is qualified, who is not qualified, what do you have to submit and so forth.
So moving into a system that is based on the title 38 system, that is based simply on the professional is hired, promoted and retained based solely on their qualifications, as opposed to going through these very complex processes that VA has been unable to implement over the past 5 years. It has been 5 years since the Congress changed the hybrid statutorily.
So we believe that it would very much not only simplify the system for psychologists, but certainly improve the recruitment of new psychologists and, clearly, the retention of psychologists, the leadership. We have a lot of psychologists in the system who have been in 20 and 30 years that are operating at the GS-13 level. They are not there for the money. They are there because of the dedication to veterans. And they need to be the folks training the new cadre of professionals.
Mr. MILLER. Thank you very much.
I apologize to Ms. Mund and Mr. Wommack. My time for questions has expired.
Mr. MICHAUD. Mr. Hare?
Mr. HARE. Thank you, Mr. Chairman.
Ms. Mund, I was wondering, could you please compare the differences between hiring, retention or educational benefits packages offered by the VA and the private sector for CRNAs? And does the VA excel in any of those areas more than the private sector?
Ms. MUND. Well, the main difference, I think, between the two is other places, what I have heard from my students, especially recent grads, are they can call up the University of Minnesota hospital and say, "I am a new grad. What am I going to start at for salary? What kind of bonus am I going to get? What can I see for loan paybacks?" And they can get that number from human resources immediately.
The problem with the VA is often they will call human resources and they will get a range just like it is posted on VA Jobs. So the student does not know where they are starting until they sign on. Often they are not going to take that chance when the range is anywhere from $89,000 to $139,000. It is difficult to see where you would fit on that scale.
The other thing is the employee debt-reduction program, which I spoke to before, which I think is a great recruitment tool. The problems is there is a 6-month window that, if you don't apply for it within that time, you are no longer eligible. Well, if for some reason paperwork has been lost, the human resources person covering that student has some lack of information, all of a sudden that 6-month window is gone and the debt-reduction program they are no longer eligible for. Other things related to that is human resources also, if it does not say on the Web site that you are eligible for the Education Debt Reduction Program (EDRP), they cannot offer that to you once you sign on.
So I think a lot of it is the transparency for when students apply for jobs. They need to see that in the VA. They need to know that these things are going to be available and rather than getting lost in the shuffle of paperwork and time.
Mr. HARE. Because it would seem to me, somebody graduates and they know at one hospital what their bonus is going to be, their salary is going to be, their compensation is going to be, almost to the penny—
Ms. MUND. Right.
Mr. HARE. —and then you have the VA who gives them a range. So if you are getting out of school with a lot of debt load, and I am sure the debt load is significant, it has got to really put us at a disadvantage, I am assuming.
I can't blame the student, I mean, obviously, because they have spent this time and, as I said, built up a lot of debt.
Ms. MUND. And I think the unfortunate thing is they primarily had their training site in the VA, and they loved taking care of veterans. There really is not another population that is like that. But after having the time and expense of school, sometimes you have to weigh those things. And I think that if we did a better job of a transparent benefit package, I think the VA could be very comparable.
Mr. HARE. Mr. Cox, can you talk a little bit more about the hybrid hiring process and what makes it so long and complicated for prospective applicants?
Mr. COX. The hybrid—again, the VA has to develop qualification standards. The way that it is sold to everyone in the beginning is that, okay, hybrid, you can just walk in, fill out an application and apply for a job. That is fine; that process is simplified. But then there is the qualifications standards, the professional standards boards. These people have to be brought in. The boards have to meet. They have to review the qualifications of the people, then establish their grade, those type things.
That is what really complicates the process. While it is not the actual application process, it is the professional standards boards, the qualifications standards that create the problems in it.
Mr. HARE. And my last question here. Dr. Phelps, outside of fair compensation, how else would uniformed leadership in the VA facilities benefit recruitment and retention of psychologists?
Dr. PHELPS. The issue of uniformed leadership is this. In the mid-1990s, when Dr. Kaiser came in, regionalized the system, got rid of discipline-based services, what happened was, not just to psychology but with other professions as well, social work—I am most familiar with the mental health side—is we had staffs reporting to other disciplines who had no understanding of what the standards of practice are within that particular discipline.
What has happened since then is a recognition by the system that the ability to certify the qualifications, the skill sets and so forth of psychologists in the system requires somebody in psychology. So we have a system where there is no uniformity. Facilities appoint a lead psychologist or a senior psychologist; there are many different terms. And this gets back to the issue of, sort of, fair pay for a fair day's work, Mr. Hare. Those folks operate in those positions in addition to their regular job description.
And part of our issue with the hybrid is national standards boards and the quality standards have recognized that those are additional responsibilities that should bring additional pay, but there is no uniformity even at the level of what those types of positions are.
Mr. HARE. Thank you.
Thank you, Mr. Chairman.
Mr. MICHAUD. Thank you, Mr. Hare.
Once again, I would like to thank our panelists. We will have some additional questions for the record, so if you could answer the questions for the record, we would appreciate it very much. Once again, thank each and every one of for coming out this morning.
Our second panel is comprised of Fred Cowell, who works for the Paralyzed Veterans of America (PVA); Adrian Atizado, of the Disabled American Veterans (DAV); and Cecilia McVey, who is the Associate Director of Patient Care and Nursing in the VA Boston Healthcare System, and Immediate Past President of the Nurses Organization of Veterans Affairs (NOVA).
I would like to welcome our second panel. I am looking forward to your testimony here this morning.
And we will start off with Mr. Cowell.
STATEMENTS OF FRED COWELL, SENIOR ASSOCIATE DIRECTOR FOR HEALTH ANALYSIS, PARALYZED VETERANS OF AMERICA; CECILIA MCVEY, BSN, MHA, RN, ASSOCIATE DIRECTOR FOR PATIENT CARE/NURSING, VETERANS AFFAIRS BOSTON HEALTHCARE SYSTEM, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND IMMEDIATE PAST PRESIDENT, NURSES ORGANIZATION OF VETERANS AFFAIRS; AND ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS
Mr. COWELL. Chairman Michaud, Ranking Member Miller and Members of the Subcommittee, on behalf of the Paralyzed Veterans of America, I am pleased to offer our views concerning the human resource challenges within the Department of Veterans Affairs.
Mr. Chairman, the Subcommittee's interest in the issues concerning VA healthcare personnel is well-placed and timely. Congress must assist VA's efforts to recruit and retain its corps of healthcare professionals as the demand for healthcare increases because of today's wars and the aging of veteran population from previous wars.
Currently, the Nation is experiencing serious shortfalls in its supply of physicians, nurses, pharmacists, therapists and psychologists. Competition for experienced medical personnel and newly licensed professionals is keen.
PVA believes that Congress must take the lead in revamping outdated personnel policies and procedures, that include salaries, benefits and working conditions, that may place VA at a disadvantage in today's labor market and will prevent VA from becoming a medical care employer of choice in the future.
PVA also believes that the broken VA appropriation process, which delays VA funding, is a major barrier to VA's healthcare professional recruitment processes.
VA nurse recruitment and retention efforts: As has been stated earlier, the United States is currently in the 10th year of a critical nursing shortage which is expected to continue through 2020. The current and emerging gap between the supply of and the demand for nurses may adversely affect the VA's ability to meet the healthcare needs of those who have served our Nation.
The VA must be able to recruit the best nurses and retain a cadre of experienced, competent nurses. Providing high-quality nursing care to the Nation's veterans is integral to VA's healthcare mission.
VA physician recruitment and retention: PVA is concerned about VA's current ability to maintain appropriate and adequate levels of physician staffing at a time when the Nation faces a pending shortage of physicians. Recent analysis by the Association of American Medical Colleges indicates the United States will face a serious doctor shortage over the next few decades. The subsequent increasing demand for doctors as many enter retirement will increase challenges to VA's recruitment and the retention efforts.
VA's psychologist recruitment, retention and appropriate promotions: According to the American Psychological Association, VA is the largest single employer of psychologists in the Nation. Congress and VA have recognized the need to increase the number of psychologists and have added more than 800 new psychologists since 2005, thereby raising the number of the psychologists in the VA system to approximately 2,400.
VA must also strive to retain and promote its more experienced psychologists in order to meet new training and supervision requirements. Since the vast majority of new psychologist hires in VA are less experienced professionals, VA must ensure they are properly trained and supervised. VA must also strive to retain and promote its more experienced psychologists in order to meet new training and supervision requirements.
Recommendations to enhance VA's recruitment retention efforts: Congress must revamp outdated VA personnel policies and procedures to streamline the VA hiring process and avoid recruitment delays that become barriers to employment.
Conduct Congressional oversight hearings to determine the extent of problems regarding national standardization and availability of VA locality pay.
Congress should implement a title 38 specialty pay provision for VA nurses providing care in VA specialized service areas, such as spinal cord injury, blind rehabilitation, mental health, and traumatic brain injury.
Review and adopt the recommendations developed by the VA's National Commission on VA Nursing. PVA believes these recommendations have broad application and can serve as a template for improvements that can assist VA's human resource management recruitment and retention efforts.
Congress should improve the provisions of VA's Education Debt Reduction Program, the EDRP. Currently, the EDRP is limited to not more than $49,000 spread out over 5 years of service. This program has not kept pace with the soaring costs of medical specialty education. Expanding benefit levels in EDRP will make VA more competitive than the national healthcare professional marketplace.
VA must also become more flexible with its work schedules to meet the needs of today's healthcare professionals.
Other benefits, such as child care, and a less stringent policy regarding mandatory overtime will make VA employment more attractive.
Congress should also consider reinstating the VA Health Professional Education Assistance Scholarship Program. This program was sunset in 1998, and the program would be an excellent medical care student incentive to future VA employment.
Finally, Mr. Chairman, PVA believes that Congress must find a solution to delays with the VA appropriation process. Delays in VA appropriations hamstring VA managers' recruitment efforts all across the country.
Mr. Chairman, this concludes my remarks. I will be h
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