Chairman Michaud, Ranking member Miller, and members of the Subcommittee, on behalf of the Paralyzed Veterans of America (PVA), I am pleased to be here today to offer our views concerning the “Human Resource Challenges within the Department of Veterans’ Affairs.” 

PVA’s primary concern, and the basic reason for our existence, is the health and welfare of our members and of our fellow veterans. The thousands of VA healthcare professionals and all of those individuals necessary to support their efforts are at the core of VA’s primary mission.  These individuals serve on the front line every day, caring for America’s wounded veterans from Iraq and Afghanistan and seeing to the complex medical needs of our countries older veterans from previous wars.  PVA believes that

VA’s most important asset is the people it employs to care for those who have served our nation. 

Mr. Chairman, the Subcommittee’s interest in the issues concerning VA health care personnel is well placed and timely.  Congress must assist VA’ efforts to recruit and retain its corps of health care professionals as the demand for health care increases because of today’s wars and the aging of the veteran population from previous wars.  Currently, the nation is experiencing serious short falls 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PVA believes that Congress must take the lead in revamping outdated personnel policies and procedures (salaries, benefits, and working conditions) that may place VA at a disadvantage in today’s labor market and will prevent VA from becoming the 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 health care professional recruitment process.

America’s National Nurse Shortage 

The United States is currently in the tenth year of a critical nursing shortage which is expected to continue through 2020.  The shortage of registered bed-side nurses and registered nurse specialists is having an impact on all aspects of acute and long-term care.  America’s nursing shortage has created nurse recruitment and retention challenges for medical-care employers nationwide and is making access to quality care difficult for consumers.

Three national issues are directly contributing to America’s national nursing shortage.  First, the number of new nursing students entering nursing education programs is insufficient to meet rising medical care demand.  Second, the number of nursing students seeking admission to nursing schools is restricted because of a lack of qualified nursing educators.  According to the American Association of Colleges of Nursing, 38,400 nursing school applicants were turned away because of a lack of faculty.  Third, a large percentage of the nation’s nurse workforce is nearing retirement and will soon need to be replaced.

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.  According to VA, it employs more than 64,000 nursing professionals, and has one of the largest nursing staffs of any health care system in the world.  Of that 64,000, VA has 43,000 registered nurses, 12,000 licensed practical nurses, and 9,000 nursing assistants.  VA also says that approximately 4,300 nurses retire or leave each year.  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 the health care mission of VA. 

Like other health care employers, VA must actively address those factors known to affect recruitment and retention of nursing personnel such as: fair compensation, professional development, work environment, respect and recognition, technology, and sound leadership.  Action is required now, to address the underlying issues of successful VA nurse recruitment and retention.  Failure to do so will undermine the quality of VA care and will jeopardize the health of our veterans.

Mr. Chairman, The National Commission on VA Nursing submitted its final report to then VA Secretary, Anthony J. Principi on March 18th, 2004[1].  The report titled, Caring for America’s Veterans: Attracting and Retaining a Quality VHA Nursing Workforce is as vital today as it was then. 

PVA supports the following recommendations contained in that report and believes they serve as a sound template for improvements to VA’s policies and procedures that govern its health care workforce.  The recommendations of the National Commission on VA Nursing were:

Leadership

• The facility nurse executive should have line authority, responsibility, and accountability for nursing practice and personnel.
• The facility nurse executive should be a member of the executive body at VISN and facility levels.
• The facility nurse executive should be accountable for (a) the effective performance of nurse managers, (b) leadership development of all nursing staff, (c) development and implementation of clinical leadership roles at the point of care, and (d) compliance with standardized Nurse Professional Standards Boards (NPSB) protocols.
• VHA should clearly define Nurse Qualification Standards to facilitate consistent interpretation across VA’s system of care.

Professional Development

• VHA should structure career development opportunities to assure that every nurse in VHA can actualize his/her goals within one or more career paths with the opportunity for professional growth and advancement.
• VHA should establish policy guidelines for schools of nursing comparable to the medical school model and actively promote nursing school affiliations.
• VHA should assure that VA’s Health Professionals Educational Assistance Program is funded and available nationwide.

Work Environment

• VHA should develop, test, and adopt nationwide staffing standards that assure adequate nursing resources and support services to achieve excellence in patient care.

NOTE:  PVA believes that nurse staffing standards must consider the acuity level of patients for these standards to be meaningful.

• VHA should review and adopt appropriate recommendations outlined in the Institute of Medicine report , Keeping Patients Safe: Transforming the Work Environment of Nurses, to determine specific strategies for implementation across VHA.

Respect and Recognition

• VHA should expand recognition of achievement and performance in its nursing service.
• VHA should create a sense of value and culture of mutual respect for nursing through all levels of VHA to include physicians and other colleagues, management, and stakeholders.

Fair Compensation

• VHA should amend Title 38 to establish procedures for assuring that RN locality pay policies are competitive with local RN employer markets.  NOTE:  PVA supports specialty nurse pay for VA nurses working in VA’s specialty care areas such as: spinal cord injury rehabilitation and sustaining care, blind rehabilitation, mental illness and traumatic brain injury.
• VHA should change hiring and compensation policies to promote recruitment and retention of licensed practical nurses and nursing assistants.
• VHA should strengthen its human resources systems and departments to develop an active hiring and recruiting process for nursing staff that is consistent, to the extent possible, across facilities and VISN’s.

Technology

• VHA should give priority to the continued rollout of the VA Nursing Outcomes Database (VANOD) as the repository for nursing performance standards and the evaluation of effective patient care delivery models.
• VHA should engage experts to evaluate and redesign nursing work processes to enhance patient care quality, improve efficiency, and decrease nurse turnover through the use of technology.
• The Agency for Healthcare Research and Quality (AHRQ) and VHA should partner in applying findings from information systems and technology research projects into patient care delivery.

Research and Innovation

• VHA should establish a Center for Excellence in Quality Nursing Care to create and implement a research agenda consistent with VHA mission.

Mr. Chairman, while these recommendations for VA improvement were directed toward VA’s Nursing Service PVA believes that they have broad application to VA’s entire health care workforce. 

Specialty Pay for VA’s Specialized Services Nurses

PVA would very much appreciate the committee’s consideration of providing specialty pay for nurses providing care in VA’s specialized service programs such as: spinal cord injury/disease (SCI/D), blind rehabilitation, mental health and brain injury.

Mr. Chairman, veterans who suffer spinal cord injury and disease require a cadre of specialty trained registered nurses to meet their complex initial rehabilitation and life- long sustaining medical care needs.  PVA’s data reveals a critical shortage of registered nurses who are providing care in VA’s SCI/D center system of care.  The complex medical and acuity needs of these veterans, makes care for them extremely difficult and demanding.  These difficult care conditions become barriers to quality registered nurse recruitment and retention.  Many of VA’s SCI/D nurses are often placed on light duty status because of injuries they sustain in their daily tasks.  When this happens it becomes a significant problem because it places additional patient care responsibility on those SCI/D nurses not on light duty.  PVA believes SCI/D specialty pay is absolutely necessary if nurse shortages are to be overcome in this VA critical care area. 

We strongly encourage your committee to create a Title 38 specialty pay provision that will assist VA’s efforts to recruit and retain nurses in these specialized areas.  PVA is eager to assist Committee staff in developing legislative language that will create specialty pay for VA nurses working in these critical care areas.

Nurse Anesthetists

VA is currently facing serious challenges to the recruitment and retention of Certified Registered Nurse Anesthetists (CRNA) who provide the majority of anesthesia care for veterans receiving care in VA medical facilities.  GAO has reported that VA medical facilities have current challenges recruiting and retaining VA CRNAs and that these facilities will likely face challenges in retaining CRNAs over the next 5 years due to the number of VA CRNAs projected to retire from or leave VA[2].  The GAO further reported that their surveys of VA officials indicated that low VA salaries were the major barrier to VA’s recruitment and retention efforts for this critical nursing skill.

VA Physicians

PVA is concerned about the 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 (AAMC) indicates the United States will face a serious doctor shortage in the next few decades.[3]  The AAMC goes on to say that currently, “744,000 doctors practice medicine in the United States, but 250,000 – one in three are over the age of 55 and are likely to retire during the next 20 years.”  The subsequent increasing demand for doctors, as many enter retirement, will increase challenges to VA’s recruitment and retention efforts.

Mr. Chairman PVA has serious concerns regarding VA’s current and future ability to match or exceed private sector physician salaries.  Additionally, PVA believes that VA’s recruitment efforts are hampered because VA’s Education Debt Reduction Program (EDRP) is limited to $49,000 spread out over 5 years of service.  The average medical education indebtedness has climbed to over $140,000 in 2007, therefore the limited VA EDRP awards fail to provide an adequate incentive for VA recruitment.    

PVA is also concerned that the P.L. 108-445, the Department of Veterans Affairs Personnel Enhancement Act, is being manipulated by facility management to reduce operation costs.  The American Federation of Government Employees (AFGE), AFL-CIO testified before the Senate Committee on Veterans Affairs that, “At many VA facilities, management has imposed improper performance criteria that determine bonuses based on factors beyond the practitioners control, such as missed appointments. [4]”  The AFGE goes on to say that annual physician performance pay awards under this law have been inconsistent and unjustifiably lower than the maximum amounts set by Congress.

The Independent Budget veterans service organizations (IBVSOs) believe that appropriate committees should use their oversight authority to study the impact of P.L. 108-445 on recruitment and retention of VA physicians and dentists.

VA Psychologists

According to the American Psychological Association (AAPA), 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 psychologists in the VA system to approximately 2,400.  The demands placed on VA’s mental health service have increased dramatically because of the wars in Iraq and Afghanistan (OIF/OEF).  However, it should be noted that these increased psychology staffing levels are a recent development.  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.

Despite VA’s positive recruitment efforts, VA’s advancement and retention policies continue to be driven by outdated and overly-rigid personnel and retention mandates.  PVA urges the Subcommittee to utilize its oversight authority to investigate VA’s on-going psychologists recruitment efforts to determine if VA is providing adequate levels of mental health care to meet the demands imposed by OIF and OEF while ensuring that adequate treatment opportunities continue to exist for veterans with prior service.

Summary

Mr. Chairman, the Veterans Health Administration has made great strides over the last decade to improve the quality of care it provides to our nation’s veterans.  Despite these gains, VA now finds itself in a precarious situation if it expects to retain its position as a vastly improved health care system.  Challenges associated with maintaining a highly qualified medical care workforce are a major issue for VA.  Competition to hire medical care professionals, during a national period of low supply, is making it more-and-more difficult for VA to successfully recruit and retain qualified personnel.

If VA is to succeed it must have the resources required to offer competitive salaries and benefits and to make improvements to its work environment.  VA must better utilize existing policy provisions that provide locality pay, premium and overtime pay, create flexible work schedules, relieve restrictions on mandatory overtime, and fully fund its excellent educational programs such as the Education Debt Reduction Program and the National Nursing Education Initiative.

Mr. Chairman, PVA believes that Congress must assist VA’s employment efforts by up-dating provisions of Title 38 that will enhance VA’s competitive position as it vies to attract health care professionals to its ranks.  Additionally, Congress must embrace a VA appropriation process that promptly funds the VA health care system so VA management can be confident that resources are available to support a health-care workforce that can meet the medical care demand of a growing veteran population.

Mr. Chairman, this concludes my remarks.  I will be happy to attempt to answer any questions you or members of the Subcommittee may have.

[1] National Commission on VA Nursing 2002-2004, Final Report, Caring for America’s Veterans: Attracting and Retaining a Quality VHA Nursing Workforce.

[2]  GAO Report April 9, 2008, VA Health Care: Recruitment and Retention Challenges and Efforts to Make Salaries Competitive for Nurse Anesthetists, GAO-08-647T.

[3] Statement before the Senate Committee on Veterans Affairs, April 9, 2008, Making VA the Workplace of Choice for Health Care Providers, by John A. McDonald, M.D., Ph.D. Vice President for Health Services and Dean of the University of Nevada Medical School and Member of the Association of American Medical Colleges, Veterans Affairs – Deans Liaison Committee.

[4] Statement before the Senate Committee on Veterans Affairs, April 9, 2008, Making VA the Workplace of Choice for Health Care Providers by Valerie O.Meara, N.P. Professional Vice President, AFGE Local 3197 VA Puget Sound Health Care System, Seattle, Washington.