Screeria nigeria. Rs staffing and then the white house news briefing and then recent Data Security breaches at banks and retailers. A hearing today looked at staffing shortages at Veterans Affairs hospitals. Witnesses representing va doctors and nurses talked about the need for more medical professionals. This house Veterans Affairs subcommittee hearing is two hours. This subcommittee will come to order. Before we begin, i would like to ask for unanimous consent for my friend and colleague from pennsylvania to sit in on todays hearings. Without objection, so ordered. Thank you for joining us today for todays subcommittee hearing, overcoming barriers to more efficient and effective va staffing. As a physician who worked at fee for service at the iran mountain Va Department of Veterans AffairsMedical Center for about 20 years i know how privileged it can be to care for veterans on a daily basis. Regardless of how fulfilling va employment often is, the departments ability to effectively and efficiently recruit and retain qualified medical professionals it to treat veterans is seriously fractured. For example, in my district at the outpatient clinic, it has not had a physician on staff for at least two years. Va has attributed that to the difficulty of recruiting physicians in rural areas. And while i understand that difficulty i think vas overtly over hiring bureaucratic process contributes to the inability to recruit a position for years running. The sioux st. Marie was unable to post a position directly. Instead, they are filtered through a Human Resource office in milwaukee wisconsin, several hours away in another state. And my understanding, all job postings are run through this one office in milwaukee. Despite repeated assurances that the department was actively recruiting for the position in sioux st. Marie, i have not seen an advertisement except for a blurb on that Hospital Website leaving me to wonder whether they know what it is supposed to look like. As important as effective recruitment is, retention of employees is critical. According to the 2014 best places to work survey the number of va employees resigning has risen every year since 2009. Its not hard to see why. The survey results ranked 18 of 19 large agencies overall. 18 of 19 in effective leadership. 19 of the 19 in pay with the departments overall score last year being the lowest va has received since the report was First Published in 2003, when a va center is inadequately staffed or make as decision to leave the va, our veterans lose out. The growing physician shortage is causing the marketplace to be more and more competitive with the association of american medical colleges projecting a 91,000 physician shortfall by 2025 if the va is going to keep pace with the private sector in recruiting and retaining the high quality providers that our veterans deserve, immediate action must be taken to improve retention of existing staff and ensure that qualified candidates for new or vacant positions are quickly identified, recruited, hired and brought aboard. Critical to that and to all vas plans regarding the delivery and quality of care is making sure those on the front lines providing direct patient care are not only involved, but leading the efforts to make the Va Health Care system stronger. To that end, im proud to have representatives from the National Association of va physicians and dentists. The va physician Dentist Association and the Nurses Association physicians of va on our Witness Panel today. They input you as well as the rest of our witnesses will provide about the daily reality you and your members face at va facilities across the country every day is invaluable. I thank you and all of our witnesses for being here this morning. And i now yield to the Ranking Member for any Opening Statement she may have. Thank you, mr. Chairman, and thank you for calling this hearing today on va staffing. Section 301 of the veterans access care and accountability act signed by the president last year mandated the va shall submit a report assessing the staffing of each medical facility of the department. This hearing will assess how they are doing in staffing around the country in respect to the care of our veterans. In its report, the va cites the need for an additional approximately 10,000 fulltime employees to supplement the approximate 180,000 employees that currently work in Veterans Health care. Im looking to find out from the va how both numbers were arrived at. One issue is that last year secretary mcdonald quoted a number of 28,000 positions needed to fully staff Va Health Care. Now we are down to just over 10,000. The staffing report concurs with the inspector generals report listing the top five occupations that are most critical. Medical officer, nurse, physician assistant, physical therapist and psychologist. One occupation not listed because its not technically Health Care Related is Human Resources. These are the people that hire and fire and generally keep a facility fully staffed. Im interested in hearing how the vha will be streamlining the hiring process and getting more people to work in a reasonable time frame to treat our veterans. Veterans in my Congressional District face barriers to access and care due to va issues. Ventura county is home to more than 47,000 veterans and our local cboc struggles with staff retention. There are high turnover rates for physicians and medical support staff. The primary care team is down to just one physician, two Nurse Practitioners and one physician assistant. We are concerned that veterans are not using important Wraparound Services because theres no primary care social worker on staff. Over the past five years the number of veterans seeking Mental Health care at the cboc has doubled and the va has been working hard to meet the growing demand, but we still seem to be in a place where were not fully staffed. I know staffing issues facing ventura can county are ones that can be found across the va system. I look forward to hearing how the va is using the funding to increase the departments workforce and high demand occupations so that the nations veterans have timely access to the high quality professional care that the va is known for. Thank you, mr. Chairman, and i yield back the balance of my time. Thank you. Joining on our first panel is joan clifford, immediate past present of the Nurses Organization of veteran affairs. Dr. Samuel spagnola. The president of veteran affairs physician assistant association. Jeff morris, the director of communications and external affairs for the american board of physician specialties. And dr. Nicol salvo from the american podiatric medical association. Miss clifford. We allow everybody five minutes. So should be a little light there when it goes red. That means youre up. Thanks. Hi. Thank you. Chairman, Ranking Member, and members of the sub committee, on behalf of the nearly 3,000 members of the Nurses Organization of veteran affairs, i would like to thank you for the opportunity to testify on todays important and timely subject, va staffing. As the department of Veterans Affairs undergoes system wide reorganization to include many challenges of implementing the veterans access choice and accountability act, staffing must be at the forefront of the evaluation. Im deputy Nurse Executive at the va boston Health Care System and im here as the immediate past president of nova. Nova is a professional organization for registered nurses employed by the va. The focus is veteran issues. Were uniquely qualified to share views to efficiently and effectively recruit and retain qualified Health Care Professionals to treat our veteran patients. As va nurses we are in the Medical Centers and at the bedside every day. We have identified retention and recruitment of Health Care Professionals as a critically important issue in providing the best care anywhere for our veterans, and we would like to offer the following observations. Nova believes that the underlying issues reside in the lack of a strong instruct for Human Resources. Insufficient Nursing Education opportunities and the complex application system. Namely usa jobs that va uses for hiring staff. We are facing a shortage of corporate experience. Insufficient hr staffing to support the multiple priorities required for Health Care Professionals. The complex hiring process with systems that do not interface lead to extended weights for job offers. As times this results in candidates accepting non va jobs and puts va back in hunt for qualified candidates. Resulting in unnecessary recruitment delays contribute to delays in hiring personnel. Reclassification and downgrades of some occupations, such as surgical technicians, who are brought in and recently downgraded to gs5 are making it impossible to competitively retain and recruit. A lack of knowledge on how to maximize the law has resulted in inconsistent application of the law, an obstacle to hiring and retention. Nova asks it be increased in order to remain competitive. Ensuring an infrastructure to sustain programs that produce nursing graduates who honor and respect the programs is vital. The office of veteran affairs has limited funds. Potentially impacting the recruitment of future hires who flock to these programs. The Nurse PractitionerResidency Program is a pilot and will require continued funding for educational infrastructure. Nova believes its a good investment as hiring Nurse Practitioners will increase access and give access to veterans nationwide. Ongoing support for Tuition Reimbursement alone tuition programs will help nurses with the cost of education if they work for va and support for va nursing partnerships is needed. An area of concern is the use of advanced practice nurses, which at this time is subject to state laws in which the facility is located. Vha is advocating full practice authority, which would result in all advanced practice registered nurses employed by the va to be able to function to the full extent of their education, license sur and training regardless of the state in which they live and work. Legislation has been introduced, hr1247. The improving veterans access to care act of 2015, which is the model already practiced by the department of defense, Indian Health service, and Public Health service systems. Nova, together with other National Nursing organizations, are calling on congress to support the legislation, which would begin to address critical needs within va facilities by improving wait times and access of care to all veterans. Va employs over 90,000 nursing personnel, which is about a third of the health care workforce. Nova believes theres no greater time to have representatives from the office of Nursing Services at the table at va organized the way it provides care and services to americas heroes. Improvements and careful review, increased training and use of the locality pay law, revising the cap on the rn pay schedule to eliminate compression as well as establishing a more user friendly application process and supporting Human Resources across the nation will go a long way towards correcting the challenges we face with staffing. Nova once again thank you for the opportunity to testify and i would be pleased to answer any questions from the committee. Thank you very much, miss clifford. Doctor spagnola, please go ahead. Mr. Chairman, we have submitted a written testimony. I will ask that that be entered into the record. I will try to keep my few comments here fairly brief. Thank you for having us here, and thank the the distinguished members of the committee for having us here. We certainly appreciate it. I am here as practicing physician with more than four decades where the va, and im here also as the president of the National Association of va physicians in dennis, usually referred to as nava. The National Association of va physicians in dennis is a 501c 4 Nonprofit Organization dedicated to improving the quality of patient care in the Va Health Care system and ensuring the doctorpatient relationship is maintained and strengthened. I appear today in pursuit of that purpose. This year it is navas celebration of it is 40th year. Nava believes the key means of enhancing care of veterans is by employing the best physicians in dennis. We believe its essential for physicians to be involved in decisions requiring delivery and quality of health care. During my many years with the va i have witnessed many changes in the va. Some good. Some not so good. Ive had the opportunity to meet nearly all of the secretaries of the va over the last 40 years get to know some of them fairly well and a few i have seen as patients. I believe all of these individuals have been good people and all with the best intentions. Im sure secretary mcdonald who i have also met with also has good intentions. Not withstanding the good intentions of these people, however, the role of the physician within the system as a leader of medical care has greatly diminished over the same period. Today most physicians in dennis feel like their opinions are neither helpful nor requested. At many centers physicians in dennis no longer are even considered professionals. But referred to simply as workers. These observations come from our members. Va docs in dennis. Men and women who want to help improve veterans care. In the late 1960s and 70s nearly all va Medical Centers were led by directors who were physicians. Today, very few centers have physician directors. The position now called the va undersecretary of health was known as the chief medical director. At that time there was a direct line from the chief of staff at the Medical Center to the chief medical director. Issues of the quality of medical care were raised and addressed by medical professionals. Today, chiefs of staff report to a clinical specialist at the centers. In more recent times, theres also been a Strong Movement to eliminate the need even to have a physician in the role of undersecretary of health. I ask, would it be wise or even possible to run the Defense Department without generals and admirals in leadership positions . We are not saying that there is no role for nonphysicians in the administration of hospitals or medical care. We are saying, however, that medical judgment should be base on years of education and patient care. Physicians are being loaded with with additional duties more appropriate. Such as typing, followup calls, patient perception and preparation. Similarly, its not cost saving nor efficient to have physicians routinely escort them from waiting rooms to exam rooms and having them help the patients get undressed. Theres a growing trend to add nonphysicians and a growing concern that a veteran may never be seen or treated by a physician while in the Va Health Care system. Veterans are seen by nonm. D. Doctors without realizing they have not seen a medical doctor. We believe this is dangerous for patients, and their families, and it may also raise ethical issues. The va is currently considering a change in the nursing handbook. There will no longer be physician oversight for the process of sedation and providing operating room anesthesia by certified registered nurse. The proposed change provides no guarantee this will provide safer patient care. Additionally, lpns with little or no psychiatric experience are taking the place of psychiatrists during intake and assessments. Taking care of patients and providing excellent care has a lot to do with providing basics and using a lot of common sense. For example, when patients are asked what is important to them, you will hear simple, straightforward commonsense questions, such as will i be admitted quickly . Is the room clean . Is there a bathroom in the room . Does the call button work . And does someone answer and arrive quickly when i need them . Does everyone speak so i can understand them . If i need help to eat will there be somebody there to help me . Do my doctors and nurses spend time and explain things so i can understand what is happening . Unfortunately, patient surveys indicate that none of the above questions are being answered very well in the va. Although the crisis last year in va did focus on access to care, this is but one small piece of the total package. Getting timely initial access is of little value if it takes months to get your hip replaced or have lung cancer removed or a colonoscopy screening because there may not be sufficient physicians or add quit access to the operating room. Timely access must be assured throughout the course of care, not just on the initial visit. Va is referred to as a Health Care System. At best, its a collecti