Witness Testimony of William J. Feeley, MSW, FACHE, Veterans Health Administration, Deputy Under Secretary for Health for Operations and Management, U.S. Department of Veterans Affairs
Mr. Chairman and members of the Committee, thank you for the invitation to appear before you today to discuss the Department of Veterans Affairs (VA), Veterans Health Administration (VHA) recruitment and retention program for health care professionals. I appreciate the opportunity to discuss our ongoing efforts in workforce and succession planning as they relate to recruitment and retention. As the Nation’s largest integrated health care delivery system, VHA’s workforce challenges mirror those of the health care industry as a whole. The Nation is in the midst of a workforce crisis in health care and VHA experiences the same pressures. I am pleased to be here today to share VHA’s innovative approaches to addressing recruitment and retention of our professional health care workforce.
Efforts to Increase the Pipeline of Health Care Workers
There is a growing realization that the supply of appropriately prepared health care workers in the Nation is inadequate to meet the needs of a growing and diverse population. This shortfall will grow more serious over the next 20 years. Enrollment in schools of nursing is not growing fast enough to meet the projected future demand. The American Association of Colleges of Nursing has reported that more than 42,000 qualified applicants were turned away from nursing schools in 2006 because of insufficient numbers of faculty, clinical sites, classroom space and clinical mentors.
In April 2007, VA launched the VA Nursing Academy to address the nationwide shortage of nurses. The purpose of the Academy is to expand the number of nursing faculty in the schools, increase student nursing enrollment by 1,000 students and promote innovations in nursing education through enhanced clinical rotations in the VA. VHA research shows that students who perform clinical rotations at a VA facility are more likely to consider VA as an employer following graduation.
The pilot program known as “Enhancing Academic Partnerships”, selected four sites from among 42 applicants. The first year begins in conjunction with the 2007-2008 academic school years. The four VA facilities and nursing schools selected include: the North Florida/South Georgia Veterans Health System and the University of Florida in Gainesville; the VA San Diego Healthcare System and San Diego State University; the VA Salt Lake City Health Care System and the University of Utah in Salt Lake City; and the VA Connecticut Healthcare System and Fairfield University in Fairfield, CT. Another four partnership sites will be selected in 2008 and 2009, for a total of 12 partnership sites in the five-year pilot program.
Another program designed to attract academically successful students of baccalaureate nursing programs and pharmacy doctorate programs to work at VA is the VA Learning Opportunities Residency (VALOR) Program. The purpose of this intern program is to develop a candidate pool of qualified and highly motivated candidates for employment. The VALOR program, offering a paid internship, gives the selected students the opportunity to develop competencies in their clinical practice in a VA facility under the guidance of a preceptor. In 2006, VHA hired 89 of the VALOR nurses who had graduated. In response to the success of the VALOR program for nurses, the pharmacy component was added in 2007 to address VA’s need for pharmacists. VHA hopes to mirror this success through the pharmacy program.
The Student Career Experience Program (SCEP) offers students work experience directly related to their academic field of study by providing formal periods of work and study while the student is attending school. This program focuses on recruiting students from minority colleges and universities and in mission critical occupations. Mission critical occupations are those that may exhibit such things as an increasing demand, high turnover, or a high volume position in VHA. VHA’s goal is to actively recruit these students for permanent employment following graduation. VA National Database for Interns (VANDI) is a newly designed database developed to track those individuals who participate in specific VA recognized internship/student programs. The strategy is to use the database to identify potential qualified applicant pool. VANDI will also assist with workforce development, diversity management and succession planning. The database will include: demographic data on interns, various educational information for interns and management officials (i.e. resume writing, Special Hiring Authorities, list of colleges and universities, links to various VA Offices, etc.), and statistical data for reports and evaluations.
The VA Cadet program is a collaborative effort between VHA’s Healthcare Retention and Recruitment Office, the Office of Nursing Service and Voluntary Service. The program targets high school students who initially come to VHA as volunteers and later convert to student employment. The goal of the program is to introduce high school students to health care occupations and encourage the pursuit of education and training in nursing or other allied health professions. Students attending allied health programs may be appointed under the student career experience program and hired into vacant positions upon graduation. Once in a permanent position for one year, they are then eligible for Employee Incentive Scholarship Program (EISP) scholarships to advance their careers.
The Graduate Health Administration Training Program (GHATP) provides practical work experience to students and recent graduates of health care administration masters programs. GHATP residents and fellows are competitively selected and upon successful completion of the programs are eligible for conversion to a VA health systems specialist position in hospital management.
The Technical Career Field (TCF) program is an internship created to recruit journeyman level staff to fill vacancies in technical career fields where current and future shortages are predicted and knowledge of VA-related issues is critical to success. Recruitment is focused on local colleges and universities. Each intern is placed with an experienced trained preceptor in a VHA facility. Interns convene for an annual conference with their peers and the program is evaluated at the national level. The program is designed to be flexible based on the changing needs of the workforce. Annually, the target positions and number of intern slots are determined based on current and projected workforce needs and program evaluation data.
Streamlining the Hiring Process
It is well known that the Government hiring process is cumbersome. In May 2007, the Human Resource Committee chartered a process redesign workgroup to streamline the recruitment process for Title 5 and Title 38 positions within VHA. This included an analysis of the recruitment process and identification of barriers and lengthy processes. In August 2007, the workgroup presented their findings and recommendations for short, intermediate and long-term improvements intended to streamline processes at the facility level and facilitate change at the national level.
VA has direct appointment authority for several occupations, including physical therapists. We recognize that the physical therapist occupation is a key to the rehabilitation of returning veterans and VHA is working with the Office of Human Resources Management (OHRM) to develop a new qualification standard. OHRM expects the revised standard to advance to collaboration with the labor unions in January 2008 and be approved for implementation in mid-summer of that year. During the interim, the existing qualification standard is being used for appointments.
National Recruitment/Media Marketing Strategies
VHA Health Care Retention & Recruitment Office (HRRO) administers national programs to promote national employment branding with VHA as the health care employer of choice. Established almost a decade ago, the brand “Best Care – Best Careers” reflects the care America’s veterans receive from VA and the excellent career opportunities available to staff and prospective employees. The brand has been reflected in the popular press in the January/February 2005 edition Washington Monthly magazine article “Best Care Anywhere” and in the recently published book Best Care Anywhere: Why VA Health Care is Better than Yours by Phillip Longman.
HRRO works at the national level to promote recruitment branding and provide tools, resources, and other materials to support both national branding and local recruiting. Some of these features are:
- VHA recruitment web site (www.VACareers.va.gov) provides extensive information on careers in VHA, job search capability, and information on Federal employment pay and benefits information.
- Public Service Announcements (PSA) promote the “preferred health care employer” image of VHA. PSA's emphasize the importance and advantage of careers with VA and focus on the personal and professional rewards of such a career.
- Online advertising through a comprehensive web advertising strategy, VA job postings are promoted on commercial employment sites and online health information networks that expand our reach to over 5000 discrete web sites. The strategy includes banner advertising that drives traffic to the VACareers web site for employment information. This advertising program generates millions of ad impressions and account for more than 100,000 visits to the VA recruitment web site each month.
- Print advertising includes both direct classified advertising and national employment branding. Local classified advertising plans are built around single job announcements and using journals, newspapers, and the web to promote positions. The national program provides ongoing exposure of VA messaging to potential hires with the intent to promote VA as a leader in patient care and to clearly state the benefits of VA employment. With advertising placed in more than 35 health professional magazines and peer review journals, VHA targets readership of over 34 million potential candidates.
- VHA Health Care Recruiters’ Toolkit, a unique virtual community internal to VHA is an online management program that coordinates national and local recruitment efforts for health care professionals. The toolkit helps recruiters combat the national recruitment shortage by placing all available recruitment tools, materials, ads, and information at their fingertips.
- National Recruitment Advisory Groups, the VHA Nurse Recruiters Advisory Board and the National Nurse Recruiters group established in the early 90’s is a collaborative network of nurse recruiters from VHA facilities across the country. The group holds membership as a subchapter of the National Association of Healthcare Recruiters and works to educate and develop nurse recruiters in VHA and to share best practices.
- National Pharmacy Recruitment Advisory Board and regional network of Pharmacy Recruiters was established in 2007.
- In 2004, VHA conducted the Nursing Recruitment and Retention Study to examine attitudes toward careers in nursing and to develop and test recruitment marketing materials and messaging for development of ads, PSA's, and brochures. In 2006, VHA conducted the Pilot program to Study Innovative Recruitment Tools to Address Nursing Shortages at Department of Veterans Affairs. This study further developed recruitment and marketing approaches using online methods and refined recruitment marketing messages and recruitment materials for nursing occupations (e.g. brochures).
- In July 2007, following qualitative research to determine why pharmacists are drawn to work at VA, the VHA Pharmacy Marketing Plan was developed. This research was supplemented by quantitative research performed by the Office of Academic Affiliations of both nurses and pharmacists in the first three and five years of employment respectively. These studies quantified the impact of student clinical experiences in VA on the decision to work at a VA facility as well as the impact of the work environment and work assignments on retention.
- In fiscal year (FY) 2007, HRRO developed a comprehensive recruitment marketing plan for recruitment in mental health occupations that used strategies listed above as well as recruitment incentives to assist with quick recruitment of these providers nationally.
Financial Incentives for Recruitment and Retention
Both a recruitment and retention tool, the Employee Incentive Scholarship Program (EISP) pays up to $32,000 for academic health care related degree programs with an average of $12,000 paid per scholarship. Since the program began in 1999, approximately 7000 VA employees have received scholarship awards for academic education programs related to Title 38 and Hybrid 38 occupations. Approximately 4000 employees have graduated from their academic programs. Scholarship recipients include registered nurses (93 percent), pharmacists, and many other allied health professionals. Focus group market research shows that staff education programs offered by VHA are considered a major factor in individuals selecting VA as their choice of employer. A 5-year analysis of program outcomes demonstrated the impact on employee retention. For example, turnover of nurse scholarship participants is 7.5 percent compared to a non-scholarship nurse turnover rate of 8.5 percent. Less than one percent of nurses leave VHA during their service obligation period (from one to three years after completion of degree).
The Education Debt Reduction Program (EDRP) provides tax free reimbursement of education loans/debt to recently hired Title 38 and Hybrid Title 38 employees. EDRP is the Title 38 equivalent to the Student Loan Repayment Program (SLRP) sponsored under Office of Personnel Management (OPM) regulations for Title 5 employees. As of August 9, 2007, there were over 5,600 health care professionals participating in EDRP. The average amount authorized per student for all years since the program’s inception is $17,000. The average award amount per employee has increased over the years from over $13,500 in FY 2002 to over $27,000 in FY 2007 as education costs have increased. While employees from 33 occupations participate in the program, 77 percent are from three mission critical occupations - registered nurse, pharmacist and physician. Resignation rates of EDRP recipients are significantly less than non-recipients as determined in a 2005 study. For physicians, the study found the resignation rate for EDRP recipients was 15.9 percent compared to 34.8 percent for non-EDRP recipients.
VHA routinely uses hiring and pay incentives established under Title 5, extended by the Secretary to Title 38 employees. There is routine use of financial recruitment incentives, retention incentives (both individual and group), special salary rates, relocation incentives and other incentives as documented in VHA’s Workforce Succession Strategic Plan.
Innovative Retention Strategies
One retention strategy that has been very successful for VHA was the approval of the physician pay legislation (Public Law 108-445, dated December 3, 2004) effective January 8, 2006. The pay of VHA physicians and dentists consists of three elements: base pay, market pay, and performance pay. The change was intended to make possible the recruitment and retention of the best qualified workforce capable of providing high quality care for eligible veterans. VA is committed to ensuring that the levels of annual pay (base pay plus market pay) for VHA physicians and dentists are fixed at levels reasonably comparable with the income of non-VA physicians and dentists performing like services. Since the physician pay legislation went into effect, physician employment has increased by 430 physicians.
An overarching mission of VHA is to develop and retain our most valuable asset— those who provide quality care to our veterans and their families. VHA invests resources to nurture and maintain an exceptionally competent workforce that is committed to providing “the best quality care anywhere.”
There is a direct impact in the relationship of organization culture and employee and patient satisfaction. For example, researchers demonstrated a positive relationship between group culture and patient satisfaction among inpatients and ambulatory care patients, such that the higher the group/teamwork culture the higher the patient satisfaction (Meterko, Mohr, & Young, Medical Care, 42(5), May 2004, 492-498).
VHA believes maintaining the health of the organization improves retention of employees in hard to recruit occupations and will continue to invest in the All Employee Survey, the Civility Respect and Engagement in the Workforce (CREW) program as well as others designed to improve organizational health. We strongly believe a healthy organizational culture ensures improved patient satisfaction and care for our veterans.
Employee Entrance and Exit Survey Analysis
In 2000, VA implemented the use of an electronic database to capture survey information from employees entering and exiting VA Service. The entrance survey is an excellent tool to compare and contrast reasons the new workforce has come to work for VHA and is an excellent tool to determine recruitment sources used by candidates (e.g. newspaper ads, employee referral, online job postings). In contrast, the exit survey tracks the reasons why staff leave VHA employment.
Survey results of 2006 and the first half of 2007 show the top reasons to work for VA were advancement/development opportunities, benefits package and job stability. The mission of serving veterans and pay were also highly rated. The exit survey shows the top reasons for leaving VHA in FY 2006 and the first half of 2007 were normal retirement, advancement elsewhere, and family matters (marriage, pregnancy, etc.). These findings provide valuable insight for developing recruitment marketing messages and establishing programs to improve retention.
Workforce Succession Planning
VHA performs extensive national workforce planning and updates and publishes a VHA Workforce Succession Strategic Plan annually. As part of this process, workforce analysis and planning is conducted in each Veterans Integrated Service Network (VISN) and national program office and then is rolled up to create a national plan. The plan addresses VHA’s strategic direction and emerging initiatives such as mental health care, polytrauma, TBI, and rural health. Mission critical occupations, which are considered shortage categories, are identified and initiatives are established at local, regional and national levels to address recruitment and retention. For each of the nationally ranked mission critical occupations a thorough historical and projected workforce analysis is conducted. Plans are established at every level to address turnover, the succession pipeline, developmental opportunities, and diversity issues. For each of the critical occupations, as well as the workforce nationwide, equal employment opportunity (EEO) comparison data is provided to ensure that VHA maintains a diverse workforce.
VHA’s workforce plan is one of the most comprehensive in government and has been recognized by OPM as a Federal best practice. VA presented at other Federal agencies and the OPM Conference, “A Best Practice Leadership Forum On Succession Management.”
The Under Secretary for Health has made a personal commitment to succession planning and ensuring VHA has a comprehensive recruitment, retention, development and succession strategy. This is a continuous process which requires on-going modifications and enhancements to our current programs.
We want to thank the Committee for their interest and support in implementing legislation that allows us to compete in the aggressive health care market.
Mr. Chairman, that concludes my statement. I am pleased to respond to any questions you or the Subcommittee members may have.