	Background

VHA’s health care mission is broad in that it provides veterans with a wide  range of health care services. Our 2016 report found that for the 5 VHA clinical occupations with the  largest staffing shortages (as identified by the VA Office of Inspector  General in January 2015), the number of employees that VHA lost  increased each year, from about 5,900 employees in fiscal year 2011 to  about 7,700 in fiscal year 2015 (the 5 occupations were physicians,  registered nurses, physician assistants, psychologists, and physical  therapists). However, for some occupations, voluntary  resignations and retirements accounted for a smaller proportion of  employee losses. For example, respondents from these 10 occupations also  said that advancement issues (34 percent) and dissatisfaction with certain  aspects of the work (20 percent) were among their primary reasons for  leaving. Oversight Improvements Needed for Nurse Recruitment and Retention Initiatives

We and others have highlighted the need for an adequate and qualified  nurse workforce to provide quality and timely care to veterans. In our 2015 report—which included staff interviews at four medical  centers—we found that VHA had multiple system-wide initiatives to recruit  and retain its nurse workforce, but three of the four VA medical centers in  our review faced challenges offering them. In addition, VHA has not evaluated the training resources provided to  nurse recruiters at VA medical centers or the overall effectiveness of the  initiatives in meeting its nurse recruitment and retention goals, or whether  any changes are needed. Nor can VHA ultimately determine  whether it has an adequate and qualified nurse workforce at its medical  centers that is sufficient to meet veterans’ health care needs. VA Has Exempted 108 VHA Occupations from the Hiring Freeze

On January 23, 2017, the administration issued an across-the-board 90- day hiring freeze applicable to federal civilian employees in the executive  branch. VHA Needs to Strengthen Its HR Capacity to Better Serve Veterans

The recruitment and retention challenges VHA is experiencing with its  clinical workforce are due, in part, to VHA’s limited HR capacity, including  (1) attrition among its HR employees and unmet staffing targets, and (2)  weak HR-related internal control functions. Moreover, as shown in figure 5, the twin  challenges of weak internal controls and limited HR capacity have had a  compounding effect, creating an environment that undermines VHA’s HR  operations and impedes its ability to improve delivery of health care  services to veterans. This lack of  oversight contributes to issues with VHA’s capacity to provide HR  functions and limits VHA’s ability to monitor HR improvement efforts and  ensure that HR offices apply policies consistently. In conclusion, VHA’s challenges recruiting and retaining clinical and HR  employees are making it difficult for VHA to meet the health care needs of  our nation’s veterans. The prior reports on which this testimony is based  made three recommendations to VA aimed at improving the oversight of  nurse recruitment and retention initiatives and seven recommendations  directed at strengthening VHA’s HR capacity. VA concurred with our  recommendations and said they are taking steps to implement them. We  will monitor VA’s progress in addressing our recommendations and report  the results of those efforts to Congress.
Why GAO Did This Study

VHA's ability to attract, hire, and retain top talent is critical to its mission to provide quality and timely care for our nation's veterans. GAO's prior work has found that VHA faces long-standing, systemic human capital challenges that limit its ability to improve delivery of health care services to veterans.
This statement is based on GAO reports issued between September 2015 and December 2016 and discusses (1) the difficulties VHA is facing in recruiting and retaining staff for key clinical positions; and (2) VHA's capacity to perform key HR functions essential to addressing these difficulties.
To conduct these studies, GAO reviewed VHA policies, directives, and other documents; analyzed VHA data; applied relevant federal internal control standards; and interviewed VA and VHA officials and staff in headquarters offices, as well as in eight VHA medical centers across the country.

What GAO Found

Challenges in recruiting and retaining both clinical and human resources (HR) employees along with weak HR-related internal control practices are undermining the Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) ability to meet the health care needs of veterans.
In July 2016, GAO found that VHA losses in its 5 clinical occupations with the largest staffing shortages, including physicians, registered nurses, and psychologists, increased from about 5,900 employees in fiscal year 2011 to about 7,700 in fiscal year 2015. Voluntary resignations and retirements were the primary drivers. VHA's exit survey indicated that advancement issues or dissatisfaction with certain aspects of the work were commonly cited as the primary reasons people left.
In September 2015, GAO found that VHA had multiple initiatives to recruit and retain its nurse workforce, but three of the four VA medical centers GAO reviewed faced challenges offering the initiatives due to, for example, a lack of sufficient HR support and competition with private sector medical facilities. GAO also found that VHA had not evaluated the training resources provided to nurse recruiters at VA medical centers. As a result, VHA is unable to determine to what extent its nurse recruitment and retention initiatives are effective and whether VHA has an adequate and qualified nurse workforce to meet veterans' health care needs.
In December 2016, GAO found that VHA's limited HR capacity combined with weak internal control practices undermined VHA's HR operations and its ability to improve delivery of health care services to veterans.
VA has exempted 108 clinical and administrative occupations from the recent hiring freeze; however, HR occupations are not among the exempt positions. A prolonged freeze could further erode VHA's capacity to provide HR services such as recruiting and hiring of staff who provide medical care to veterans.

What GAO Recommends

GAO previously made three recommendations to VA aimed at improving oversight of nurse recruitment and retention initiatives and seven recommendations directed at strengthening VHA's HR capacity. VA concurred with GAO's recommendations and is taking steps to implement them. GAO will monitor VA's progress.