Joy J. Ilem
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to testify on recruitment and retention of healthcare professionals by the Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA). Without question, recruitment and retention of high caliber healthcare professionals is critical to VHA’s mission and essential to providing safe, high quality healthcare services to sick and disabled veterans. Given the impact of the nationwide nursing shortage and reports of continued difficulty in filling nursing, specialty physician and other key positions in VHA, this is an important and timely hearing.
NATIONAL COMMISSION ON VA NURSING
The environment of VHA, like America’s health care enterprise in general, is ever-changing and confronted with new challenges at every turn. Since 2000, VA has been working to address the ever-increasing demand for medical services while coping with the impact of a rising national nursing shortage. In 2001, VHA’s Nursing Strategic Healthcare Group released
A Call to Action—VA’s Response to the National Nursing Shortage. Since that time, health manpower shortages, and plans to address them, have been dominant themes of numerous conferences, reports by the General Accountability Office (GAO) and other reviewers, and Congressional hearings.
One part of the equation that has remained paramount in the discussion, concerns VA’s ability to compete in local labor markets, given the barriers that impede nursing recruitment and retention in general. Based on work in this Subcommittee, in 2002 the National Commission on VA Nursing (hereinafter the Commission), was established by Public Law 107-135. The Commission was charged to examine and consider VA programs, and to recommend legislative, organizational and policy changes to enhance the recruitment and retention of nurses and other nursing personnel, and to address the future of the nursing profession within VHA. The Commission members were a group of distinguished leaders in nursing, medicine, labor, academic management, veterans’ affairs and other relevant fields, including DAV’s Washington Headquarters Executive Director, David W. Gorman. The Commission envisioned a desired “future state” for VHA nursing, and made recommendations to achieve that vision. In May 2004, the Commission published its final report to Congress—Caring for America’s Veterans: Attracting and Retaining a Quality VHA Nursing Workforce.
Illustrative of the Commission’s findings and recommendations is this synopsis in its final report:
"Recruiting and retaining nursing personnel are priority issues for every healthcare system in America. VHA is no exception. With the aging of the population, including veterans, and the U.S. involvement in military activity around the world, VHA will experience increasing numbers of enrolled veterans. Consequently, as the demand for nursing care increases, the nation will grapple with a shortage of nurses that is likely to worsen as baby boomer nurses retire. VHA must attract and retain nurses who can help assure that VHA continues to deliver the highest quality care to veterans. Further, VHA must envision, develop, and test new roles for nurses and nursing as biotechnologies and innovations change the way healthcare is delivered."
The Office of Nursing Service in VA Central Office developed a strategic plan to guide national efforts to advance nursing practice within VHA, and engage nurses across the system to participate in shaping the future of VA nursing practice. This strategic plan embraces six patient-centered goals that encompass and address a number of the recommendations of the Commission.
- Leadership Development: supporting and developing new nurse leaders, and creating a pipeline to continuously “grow” nursing leaders throughout the organization;
- Technology and System Design: creating mechanisms to obtain and manage clinical and administrative data to empower decision-making. The objective is to develop and enhance systems and technology to support nursing roles. The Commission report highlighted the importance of nursing input in the development stage of new technologies for patient care;
- Care Coordination and Patient Self-Management: promoting and recognizing innovations in care delivery and facilitating care coordination and patient self-management. The objectives are to strengthen nursing practice for the provision of high-quality, reliable, timely, and efficient care in all settings and to enhance the use of evidence-based nursing practice. This goal also encompasses recommendations from the Commission related to the work environment of VA nurses;
- Workforce Development: improving the recognition of, and opportunities for, the VA nursing workforce. Areas of emphasis are (1) utilization: to maximize the effective use of the available workforce; (2) retention: to retain a qualified and highly skilled nursing workforce; (3) recruitment: to recruit a highly qualified and diverse nursing staff into VHA; and (4) outreach: to improve the image of nursing and promote nursing as a career choice through increased collaboration with external partners. The Commission report addresses all of these areas as critical to the future of VA nursing;
- Collaboration: forging relationships with professional partners within VA, across the Federal community, and in public and private sectors. The objective is to strengthen collaborations in order to leverage resources, contribute to the knowledge base, offer consultation, and lead the advancement of the profession of nursing for the broader community. The priorities of this goal align with VHA’s Vision 2020 and the Commission recommendations related to collaboration and professional development; and,
- Evidence-Based Nursing Practice: identifying and measuring key indicators to support evidence-based nursing practice. The objective is to develop a standardized methodology to collect data related to nursing-sensitive indicators of quality, workload and performance within VHA facilities.
DAV believes the Commission’s legislative and organizational recommendations served as a blueprint for the reinvention of VA nursing. Having followed that blueprint, the VHA’s strategic plan serves as a solid foundation for the creation of a delivery system that meets the needs of our nation’s sick and disabled veterans while supporting those who provide their care. Therefore, we urge Congress to continue to provide appropriations for, and oversight of, VA health care to enable VHA to invest more resources—human, financial and technological—to carry out an aggressive agenda to improve VA’s abilities to recruit and retain sufficient nursing manpower while proactively testing new and emerging nursing roles in VA healthcare.
CURRENT WORKFORCE—FUTURE NEEDS
One of VA’s most significant challenges is dealing effectively with succession—especially in the health sciences and technical fields that so characterize contemporary American medicine and healthcare delivery. DAV believes the Subcommittee and Full Committee should be particularly mindful of VA’s progress in gaining a greater foothold on succession planning.
VHA’s Succession Strategic Plan for Fiscal Year (FY) 2006-2010 reports: “VHA faces significant challenges in ensuring it has the appropriate workforce to meet current and future needs. These challenges include continuing to compete for talent as the national economy changes over time, and recruiting and retaining health care workers in the face of significant anticipated workforce supply and demand gaps in the health care sector in the near future. These challenges are further exacerbated by an aging federal workforce and an increasing percentage of VHA employees who receive retirement eligibility each year.”
In April 2007 VHA conducted a national conference, titled, VHA Succession Planning and Workforce Development. The conference report indicated the average age of all VHA employees in 2006 to be 48 years. It estimated that by the end of 2012, approximately 91,700 VHA employees, or 44% of current full time and part time staff, would be eligible for full civil service retirement. The report also indicated approximately 46,300 VHA employees are projected to retire during that same period. Additionally, a significant number of healthcare professionals in leadership positions would also be eligible to retire by the end of 2012. In a startling finding the report concluded that 97% of VA nurses in pay band “V” positions would be eligible to retire, and that 56% were expected to retire; and, that 81% of VA physicians in pay category 16—including many current Chiefs of Staff, would be eligible to retire, with 44% projected to actually retire from Federal service.
In its assessment of current and future workforce needs, VHA identified registered nurses (RN) as its top occupational challenge, with licensed practical/vocational nurses and nursing assistants also among the top ten occupations with critical recruitment needs. Currently, VA employs over 62,000nursing personnel, including about 42,000 registered nurses (RN), 11,400 licensed vocational or practical nurses, and 9,100 nursing assistants. According to VA in fiscal year 2005 (most recent data available), 77.7% of all VHA RN resignations occurred within the first five years of employment. Nurse turnover for that same period was 9.1%. Vacancy and turnover rates continue to be reported as lower than the national rates for all nurses, but did rise in 2004.
Over the past several years VHA has been searching to attract younger nurses into VA healthcare, and to create incentives to keep them in the VA system. DAV is pleased that VHA continues its positive trend as an employer of choice for men and ethnic minorities in nursing careers. According to the Health Resources and Services Administration, by 2015 all 50 States will experience a shortage of nurses to varying degrees. However, the American Association of Colleges of Nursing has reported that three-fourths of the nation’s schools of nursing acknowledge faculty shortages along with insufficient clinical practicum sites, lack of classroom space, and budget constraints as reasons for denying admission to qualified applicants. In 2005 (most recent data available) schools and colleges of nursing turned away 41,683 qualified applicants.
Earlier this year, to address this problem and attain a more stable nursing corps, VA initiated a “Nursing Academy” pilot program. VA reports its Nursing Academy will be committed to nursing education and practice, and will address the nursing shortages in VA while aiding the nation’s needs for nurses as well. VA’s pilot program for fiscal years 2007-2012 will partner with the University of Florida, San Diego State University, the University of Utah, and Connecticut’s Fairfield University, with their respective VA affiliates at Gainesville, San Diego, Salt Lake City and West Haven. The curriculum and the practicum policies of these affiliations will be developed jointly by the partners. Similar to VA’s longstanding relationships with schools of medicine nationwide, VA nurses with qualified expertise will be appointed as faculty members at the affiliated schools of nursing. Academy students will be offered VA-funded scholarships in exchange for defined periods of VA employment subsequent to graduation and successful State licensure. VA notes that in order for this program to move forward, legislation will be required to reactivate the VA’s Health Professions Educational Assistance Program (38 U.S.C. 7601-7636), an authority that expired December 31, 1998.
We urge Congress to reauthorize and fund these provisions to aid VA in establishing the Nursing Academy. According to VA, funding for the five-year pilot program, (with a total five-year cost of $85 million), will be provided from available VA Medical Services funds, but to extend the pilot or expand it further will require new appropriations. VA is hopeful that the investment made in helping to educate a new generation of nurses, coupled with the requirement that scholarship recipients serve a period of obligated service in VA health care following graduation, will help VA cultivate and retain quality healthcare staff, even during a time of nationwide shortage.
VA NURSING WORKPLACE ISSUES
Mr. Chairman, DAV continues to hear reports that VHA staffing levels are frequently so marginal that any loss of staff—even one individual in some cases, can result in a critical staffing shortage and present significant local clinical challenges. Additionally, inadequate funding has resulted in “unofficial” hiring freezes in some locations. These freezes and delays in hiring have had a negative impact on the VA nursing workforce as some nurses have been forced to assume non-nursing duties due to shortages of ward secretaries and other key support personnel. These staffing deficiencies impact both patient programs and VA’s ability to retain an adequate nursing workforce. Staffing shortages or freezes on hiring can result in the cancellation or delay of elective surgeries and closure of intensive care unit beds. It can also cause unavoidable referrals of veterans to private facilities—ultimately at greater overall cost to VA. This situation is complicated by the fact that VHA has downsized inpatient capacity in an effort to provide more services on a primary care basis. The remainder inpatient population is generally more acute, often with co-morbid conditions, lengthier inpatient episodes, complications, and needing more skilled care and staff-intensive aftercare. It has also been reported to us that in some locations, VA is overusing overtime, including “mandatory overtime;” reducing flexibility in tours of duty for nurses; and, limiting nurse locality pay. These actions, driven by short financing and extremely tight local budgets, including the current situation of a Continuing Resolution that restricts overall management discretion nationwide, creates a working environment that compromises patient safety with staff burnout, creates morale problems, produces inadequate staffing levels, and requires the use of older, inferior technology in some VA facilities. Given that VA has made so much progress in establishing the current national standard of excellence in providing care to its large veteran population, these reports.
Mr. Chairman, in testimony to this Committee in 2003, VA’s top nurse executive stated the following: “Published findings underscore the need to focus on improving the work environment for nurses in order to increase staff satisfaction and to ensure the provision of safe, high quality patient care.” We believe many of those difficult conditions in VHA continue to exist today for VA’s nursing staff, despite the best efforts and intentions of those involved. Therefore, we hope this Subcommittee will provide additional oversight to ensure a safe environment for both patients and staff.
Like other health care employers, VHA must actively address those factors known to affect recruitment and retention of all health care providers and nursing staff, and take proactive measures to stem crises before they occur. We encourage VHA to continue its quest to deal with shortages of health manpower in ways that keep VHA at the top of the standards of care in this country. We are very encouraged with the Nursing Academy proposal, endorsed by the Nursing Commission and hope that it proves it’s worth early so that it can be expanded beyond the four pilot sites. We ask the Subcommittee to pay special attention to the development of that Academy and to encourage its expansion.
PAY REFORM ISSUES FOR VA PHYSICIANS AND DENTISTS
In 2004, as reported by this Committee, Congress passed the Department of Veterans Affairs Personnel Enhancement Act, Public Law 108-445. This new law reformed the pay and performance system used by VA in employment of physicians and dentists. This proposal was one of VA’s top legislative goals in the 108th Congress. Enactment of this proposal was supported by DAV and other organizations that expressed concern that VA needed new authority to attract and retain the best physicians and dentists for the care of sick and disabled veterans—particularly at a time of ongoing military engagements in Iraq and Afghanistan. VA implemented this new authority as required by the Act in January 2006, and began to announce new pay plans for VA physicians under its terms. This Act is the most significant reform of pay systems for VA employees since the enactment of the Civil Service Reform Act in 1978, and represents the first real reform in VA physician pay since 1991.
We believe the Committee should use its oversight authority to study the impact of Public Law 108-445 on recruitment and retention of VA physicians and dentists—especially those who practice in some of the more scarce specialties, including anesthesiology, orthopedics, and various surgical specialties. These subspecialties are very scarce and VA has historically had great challenges recruiting these practitioners to full-time employment. VA’s motivation to secure this new authority was driven by the exorbitant cost of procuring contract services of scarce medical specialists. One of the purposes of the Act was to give VA the tools to enable it to attract even these specialists to VA employment on a full-time basis. Also, the crafting of the bill was designed to attract to VA young physicians first entering their professional practices after residencies, and to provide them meaningful incentives that pointed them to full careers in the VA health care system.
We believe the Committee should investigate whether the Act is resulting in VA’s improving its ability to achieve these goals. Physicians are essential caregivers, educators, and key biomedical researchers in the VA health care system. This Act was intended for their benefit, to attract them to VA careers and to keep them providing outstanding care to veterans. We would hope these purposes would be transparent and that VA would have moved implementation toward these goals, but we believe the Committee should confirm those intended results.
VA PHYSICIAN WORKPLACE ISSUES
Mr. Chairman, DAV is concerned about the stressful working environment now confronting the VA physician workforce. While the matters brought to our attention over the past few years as VA clinical workloads have grown might be dismissed as anecdotal and not indicative of the general national environment, they are no less disturbing. We have been told by numerous sources that many VA medical center directors have established arbitrary “caps” on the total bonus a VA physician may receive under the performance element of pay. While the Act gave the VA Secretary discretion by regulation to determine appropriate pay levels, it allowed for annual performance pay up to $15,000 or not to exceed 7.5 percent of combined base and market pay amounts. Directors should not, given those limitations, be permitted to establish arbitrary performance pay amounts of as little as $1,000 (we have been told this to be the case in some facilities), thereby frustrating the purposes of the Act. Also, we are in possession of a letter written by a group of VA physicians. This was a signed letter to the clinical manager of a VA network. Let me excerpt only a few of the concerns it expresses, which we fear may be suggestive of the workplace situation across the VA system:
“First, we are understaffed. Over the past 1 ½ years, we have lost a net of three physicians and one nurse practitioner at the _ _ _ _ _ site. We all have had to absorb those provider panels into our own, at a rapid pace. You stated that we had grown by fewer than 200 new patients since January; however, that statistic misses how we have added literally thousands of our former colleagues’ patients into our own panels. Our CBOC colleagues are suffering from similar provider shortages and turnover; in a single month this spring the Bangor CBOC lost two out of seven providers. At _ _ _ _ _, half of us are at or above full panel, and the other half of us are virtually at full panel. We have had no success so far at recruiting new providers, and we do not see evidence of strong administration commitment to recruitment. Further, it was known many, many months in advance that we would be losing a Women’s Clinic provider to her deployment to Iraq, yet there was no leadership in making sure a temporary provider was ready to step into her place. In fact, there seemed to be obstruction to an on-site willing provider starting work in Women’s Clinic. Again, current providers have had to absorb the workload of the absent provider.”
“We are not only understaffed in terms of providers; we are also working without adequate numbers of support staff. Specifically, within the past year, we at _ _ _ _ _ lost two pharmacists who used to work directly with us in the clinic; to date these positions have not been filled. Our CBOC colleagues are overwhelmed by the extra work that an understaffed pharmacy creates. At the CBOCs, the providers spend inordinate amounts of time writing and documenting prescriptions for veterans to fill locally, when our pharmacy does not fill the medications in a timely fashion. At both _ _ _ _ _ and the CBOCs we now have fewer nurses as well.”
We at DAV certainly hope these are isolated matters but we believe we could obtain similar responses from many other VA physician groups, in primary care and elsewhere, now shouldering a very heavy burden in caring for veterans. If the general situation in clinical care across the VA is anything like this report suggests, VA has a very serious and rising morale problem that eventually may interfere with health care quality, safety, efficiency and effectiveness. We ask the Subcommittee to consider conducting a survey of VA facilities to gauge conditions of employment and the current morale of the VA physician workforce. We believe this examination could be very informative to the Subcommittee, to VA Central Office, and to the VSO community that is so concerned about sustaining quality VA health care.
SUMMARY AND CLOSING
Mr. Chairman, in summary, DAV believes that VA must devote sufficient resources to avert the national shortage of nurses from creeping into and potentially overwhelming VA’s critical healthcare programs, and to minimize the impact that the nursing shortage on the care VA provides to sick and disabled veterans. In that regard, DAV supports VA’s strategic goals for nursing, including establishment of the innovative VHA Nursing Academy, and urges the Committee to act on legislation that would reauthorize the scholarship program. Also, we ask that you use your oversight powers to ensure the intent of Public Law 108-445 is fully realized.
This Subcommittee should provide oversight to ensure sufficient physicians and nursing staffing levels, and to regulate, and reduce to a minimum, VA’s use of mandatory overtime for VA registered nurses. We believe this practice of mandatory overtime endangers the quality of care and safety of veterans in VA health care. We believe VA should establish innovative recruitment programs to remain competitive with private-sector health care marketing and advertising strategies, to attract nurses and doctors to VA careers. While we applaud what VA is trying to do in improving its nursing programs, these competitive strategies are yet to be fully developed or deployed in VA. Also, Congress must provide sufficient funding through regular appropriations that are provided on time, to support programs to recruit and retain critical nursing staff to VA. The routine annual Continuing Resolution process negatively impacts not only VA nursing but all of VHA. We also believe the VA workplace situation with respect to both nurses and physicians deserves greater oversight by the Subcommittee, and we hope you will take our recommendations in that regard into consideration.
Again, we thank you for this opportunity to testify. We ask the Committee to consider these situations as it deals with its legislative plans for this year. This concludes my testimony, and I will happy to address any questions from the Chairman or other Members of the Subcommittee.