STATEMENT OF
JOLEEN CLARK
CHIEF OFFICER, WORKFORCE MANAGEMENT AND CONSULTING
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
HOUSE COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON HEALTH

May 22, 2008

Mr. Chairman and members of the Committee, thank you for the invitation to appear before you to discuss "Human Resources Challenges" within the Department of Veterans Affairs' ( VA) Veterans Health Administration ( VHA). Our challenges cover recruitment and retention programs, improving and streamlining the recruitment process, and other issues related to developing and maintaining a qualified and diverse workforce of health care professionals.

As the nation's largest integrated health care delivery system, VHA's workforce challenges mirror those of the health care industry as a whole. VHA experiences pressures equal to or greater than other health care organizations. VHA performs extensive national workforce planning and annually publishes a Workforce Succession Strategic Plan that includes workforce analysis and planning for each Veterans Integrated Service Network ( VISN) and national program office. VHA's Strategic Plan addresses current and emerging initiatives in areas including, but not limited to, recruitment and retention, mental health care, polytrauma, traumatic brain injury, and rural health to address workforce efforts.

VHA's Strategic Plan identifies mission-critical occupations which are considered shortage categories, as well as recruitment and retention initiatives at the local, regional and national levels. For each of the nationally-ranked mission critical occupations, VA conducts a thorough historical and projected workforce analysis. Plans are established at every level to address turnover, succession planning, developmental opportunities, and diversity issues. VHA uses equal employment opportunity comparison data for each of the critical occupations, as well as the workforce nationwide, 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 has presented it to other Federal agencies as well as by means of OPM's "A Best Practice Leadership Forum On Succession Management" conference.

Efforts to Recruit Health Care Professionals
It is important that the supply of appropriately prepared health care workers meet the needs of a growing and diverse population. Enrollment in nursing schools needs to grow to meet the projected future demand for health care providers.

More than 100,000 health professional trainees come to VA facilities each year for clinical learning experiences. Many of these trainees are near the end of their education or training programs and become a substantial recruitment pool for VA employment as health professionals. The annual VHA Learners' Perceptions Survey shows trainees were twice as likely to consider VA employment after completing their VA learning experiences than they were before. This demonstrates many trainees were not aware of VA employment opportunities or the quality of VA's health care environment prior to VA training, but became considerably more interested after their VA clinical experiences.

An informal survey of all VA facilities in 2007 found that 74 percent of the 800 psychologists hired over the last three years received some training in professional psychology through VA. This year, VHA's Offices of Academic Affiliations and Patient Care Services significantly expanded VA's psychology training programs in anticipation of the ongoing need for additional VA psychologists.

The Healthcare Retention and Recruitment Office ( HRRO) is distributing a new recruitment brochure titled "From Classroom to Career" to VA trainees. The Office of Academic Affiliations in VA Central Office emphasizes trainee recruitment to education leaders in VA facilities. The VHA leadership has raised the trainee recruitment issue to a higher priority.

In an effort to initiate proactive strategies to aid in the shortage of clinical faculty, VA launched the VA Nursing Academy (Academy) to address the nationwide shortage of nurses. The purpose of the Academy is to expand the number of nursing faculty in schools, increase student nursing enrollment by 1,000 students, increase the number of students who come to VA for their clinical learning experience, and promote innovations in nursing education and clinical practice. Four partnerships were established for the 2007-2008 school year. Four additional partnerships will be selected each year in 2008 and 2009 for a total of twelve partnerships.

The VA Travel Nurse Corps is an exciting new program that established a pool of registered nurses ( RNs) in VA who can be available for temporary, short-term assignments at VA medical centers throughout the country; this program is being piloted at two sites, San Diego and Phoenix. The VA Travel Nurse Corps meets nurses' needs for travel and flexibility while meeting VA medical center needs for temporary, high quality nurses. The goals of the program are to maintain high standards of patient care quality and safety; reduce the use of outside supplemental staffing; improve recruitment of new nurses into the VA system; improve retention by decreasing turnover of newly recruited nurses; provide alternatives for experienced nurses who may leave the VA system; and establish a potential pool of RNs for national emergency preparedness efforts. The VA Travel Nurse Corps program may also serve as a model for an expanded multidisciplinary VA Travel Corps in the future.

Student programs, such as the VA Learning Opportunities Residency ( VALOR) Program, the Student Career Experience Program ( SCEP), and the Hispanic Association of Colleges and Universities Internship Program, have helped VA meet its workforce succession needs. VALOR is designed to attract academically successful students of baccalaureate nursing programs and pharmacy doctorate programs. VALOR offers a paid internship and gives the honor students the opportunity to develop competencies in their clinical practice in a VA facility under the guidance of a preceptor. In response to the success of the VALOR program for nurses, VA added a pharmacy component in 2007. SCEP and Hispanic Association of Colleges and Universities offer students work experience related to their academic field of study. VHA's goal is to actively recruit these students for permanent employment following graduation. VA National Database for Interns is a newly designed database developed to track students in VA internship/student programs and to create a qualified applicant pool.

The Graduate Health Administration Training Program provides practical work experience to students and recent graduates of health care administration masters programs. On an annual basis, 40-45 Graduate Health Administration Training Program residents and fellows are competitively selected and, upon successful completion of the programs, are eligible for conversion to a permanent position. The Technical Career Field program is designed to fill entry level vacancies in areas like Budget, Finance, Human Resources, and Engineering, where shortages are predicted and VA-specific knowledge is critical to success. Recruitment is focused on colleges and universities. Each intern is placed with an experienced preceptor in a VHA facility. The program is designed to be flexible and responsive to the changing needs of the workforce, as the target positions and the number of intern slots are determined based on projected needs.

Challenges Hiring Health Professional in Rural Areas
VA recognizes that rural communities face additional health care workforce challenges. Many of the access and quality challenges rural patients face begin with a shortage of health care providers. VA is working to develop an effective rural workforce strategy to recruit locally for a broad range of health-related professions.

Experiential training opportunities for young medical students are important investments for creating a veteran- and rural-friendly physician workforce. VA is working to integrate rural areas into residency rotations, since evidence shows those who serve residencies in rural areas are more likely to practice in rural areas.

Streamlining the Hiring Process
Last year, VHA's Human Resource Committee chartered a workgroup to streamline the recruitment process for Title 5 and Title 38 positions within VHA. The workgroup initially analyzed the recruitment process and identified barriers and lengthy processes for Registered Nurses. VHA conducted a pilot program in VISN 4 (Pittsburgh, PA) where the group's recommendations were put into practice. The recommendations were piloted there with the implementation and results of the pilot rolled out nationwide using information from this pilot. This spring and summer, VA is offering training in systems redesign nationally at Human Resources Cluster meetings. These sessions will focus on new strategies and systems redesign elements that can be used to help meet the daily challenges of attracting and retaining critical health care professionals. VA has direct appointment authority for several Title 38 occupations, including physical therapists. We recognize that physical therapists are essential to the rehabilitation of injured veterans, and VHA is in the final stages of working with the Office of Human Resources Management to develop a new qualification standard, which should be implemented later this year.

In October 2007, VHA consolidated the Delegated Examining Units from 19 decentralized units to eight centralized units, fully automated offices which process all VHA requests for external Title 5 job applicants. The centralization, consolidation and automation of this function have helped VHA achieve reductions in the timeframes for announcing Title 5 positions to the general public; qualifying candidates and generating certificates of eligible candidates for hiring managers. Metrics have been established and tracking implemented to measure the competitive hiring process within VHA. Improvements in timelines for processing are expected to continue throughout the year.

Innovative Retention Strategies
One retention strategy that has proven very successful for VHA was approved in Public Law 108-445 (dated December 3, 2004 and effective January 8, 2006). VHA physician and dentist pay consists of three elements: base pay, market pay, and performance pay. PL 108-445 improves VA's ability to recruit and retain the best qualified workforce capable of providing high quality care for eligible veterans. VA is committed to ensuring 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 similar services. Between the time the pay bill went into effect and the end of February 2008, we have increased the number of VA physicians by over 1,430 FTE. Also as a component of this legislation, VA has the discretionary ability to set Nurse Executive Pay to ensure we continue to successfully recruit and retain nursing leaders.

National Recruitment/Media Marketing Strategies
The VHA Healthcare Retention & Recruitment Office ( HRRO) administers national programs to promote 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.

Recent marketing studies for nursing and pharmacy have been the driving force for many of our successful campaigns. HRRO works at the national level to promote recruitment branding and to provide tools, resources, and other materials to support both national branding and local recruiting. The current annual recruitment advertising budget is $1.8 million. Some of the features of this program are:

• Integration of VHA's recruitment website search engine (www.VACareers.va.gov) with the USA Jobs (www.USAjobs.opm.gov) search engine. This combined resource provides consolidated information on careers in VHA, job search capability, and information on Federal employment pay and benefits information. This integration was completed in March 2008.
• Public Service Announcements (PSAs) promote the "preferred health care employer" image of VHA. PSAs emphasize the importance and advantage of careers with VA and focus on the personal and professional rewards of such a career.
• A comprehensive online advertising strategy where VA positions are promoted on commercial employment websites like Career Builder, Healthcareers, and others. Advertising on online health information networks expands our reach to over 5,000 discrete websites at a cost of just over $500,000 annually. VA's strategy includes banner advertising directing traffic to the VACareers website for employment information and adding keyword searches to Google and Yahoo to elevate VA jobs to the top of the list of search results on these sites. This advertising results in over 100,000 visits to the VA recruitment website each month.
• Print advertising includes both direct classified advertising and national employment branding. The national program provides ongoing exposure of VA messaging to potential employees and promotes VA as a leader in patient care. VHA print advertising reaches over 34 million potential candidates.
• VHA Health Care Recruiters' Toolkit is a unique virtual community internal to VHA. This toolkit is an online management program coordinating national and local recruitment efforts for health care professionals and serves as a resource by providing available recruitment tools, materials, advertisements, and other related information at recruiters' fingertips.
• VHA's National Recruitment Advisory Groups represent top mission critical occupations that collaborate on an interdisciplinary approach to address recruitment and retention.

In Fiscal Year 2007, HRRO developed a comprehensive recruitment marketing plan for mental health professionals using some of the strategies mentioned earlier, as well as financial recruitment incentives. Funding was dedicated for Mental Health Enhancement Initiative Education Debt Reduction Program ( EDRP) positions. As of May 1, 2008, awards had been made to 144 participants. The total payout for these participants is over $5,235,000 over a five-year service period. The average total award is $36,355.

Financial Incentives for Recruitment and Retention
Both a recruitment and retention tool, the Employee Incentive Scholarship Program (EISP) pays up to $35,900 for academic health care-related degree programs. Between 1999 and May 1, 2008, 7,524 VA employees have received scholarship awards for academic education programs related to Title 38 and Hybrid Title 38 occupations, and more than 4,200 employees have graduated. Scholarship recipients include RNs (93 percent), pharmacists, and many other allied health professionals. Focus group market research shows staff education programs offered by VHA are considered a major factor in individuals selecting VA as their choice of employer. A five-year analysis of program outcomes demonstrated positive employee retention. 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 similar to the Student Loan Repayment Program, under Office of Personnel Management (OPM) regulations. VA has the authority to award up to $50,824. Currently, the maximum award amount is capped at $48,000 and is tax free. The maximum award amount is usually increased each fiscal year. As of May 1, 2008, 6,467 health care professionals were participating in EDRP. The average amount authorized per student, since the inception of EDRP, is $18,394. The average award amount per employee has increased each fiscal year from over $13,500 in FY 2002 to over $29,000 in FY 2008 as education costs have increased. While employees from 34 occupations participate in the program, 75 percent are from three mission critical occupations: registered nurses, pharmacists and physicians. These figures include the mental health initiative EDRP awards discussed previously.

Resignation rates of EDRP recipients are significantly less than non-recipients as determined in a 2005 study that showed:

• The resignation rate for nursing EDRP recipients was 14.3 percent while the resignation rate for non- EDRP recipients was 28 percent - a 13.7 percent difference. The resignation rate for physician EDRP recipients was 15.9 percent while the resignation rate for non- EDRP recipients was 34.8 percent - an 18.9 percent difference. The resignation rate for pharmacy EDRP recipients was 13.4 percent while the resignation rate for non- EDRP recipients was 27.6 percent - a 14.2 percent difference.

A study of the EDRP program retention rates in 2007 showed 75 percent of pharmacists and nurses who received EDRP awards in 2002 were still employed by VA at the end of the initial five-year period of the program's operation. Among physicians, 65 percent were still employed. Although a smaller percentage, it represents a substantial retention level.

VHA routinely uses hiring and pay incentives established under Title 5 and Title 38. Financial recruitment incentives, retention incentives (both individual and group), special salary rates, relocation incentives and other incentives are routinely used and documented in VHA's Workforce Succession Strategic Plan. Recruitment and retention incentives are used to reduce turnover rates and help fill vacancies. In Fiscal Year 2007, nearly $24 million in recruitment incentives were provided to over 3,150 Title 38 and Title 38 Hybrid employees, while more than $34 million in retention incentives were given to 5,300 Title 38 and Title 38 Hybrid employees.

Employee Entrance and Exit Survey Analysis
In 2000, VA began using an electronic database to capture survey information from employees entering and exiting VA service. The entrance survey is an excellent tool for comparing and contrasting reasons the new workforce has come to work for VHA and for determining recruitment sources used by candidates (for example, newspaper advertisements, employee referrals, online job postings, etc.). The exit survey tracks the reasons why staff leaves VHA employment.

Survey results of 2006 and the first half of 2007 show advancement and development opportunities, benefits, and job stability were the top reasons to work for VA. VA's 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 opportunities elsewhere, and family matters (marriage, pregnancy, etc.). These findings provide valuable insight for developing recruitment marketing messages and establishing programs to improve retention.

Conclusion
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.

I would like to thank the Committee for your interest and support in implementing legislation that allows us to compete in the health care market.