Many career managers and caregivers at the Department of Veterans Affairs (VA) experienced the Trump administration as a four-year wrecking ball. Trumps political appointees waged war on Veterans Health Administration (VHA) caregivers and their unions, like the American Federation of Government Employees (AFGE) and National Nurses United (NNU).
More of the VHA budget is being spent on outsourced care, as part of Trumps push to privatize the agency. The White House left 50,000 vacancies unfilled, until COVID-19 forced Trumps VA secretary, Robert Wilkie, to spend emergency congressional funds on thousands of new hires in 2020.
As one final blow to efficient VA functioning, Wilkie also implemented a human resources modernization (HRM) plan that has become a poison pill for VHA caregivers and administrators. The system, which remains in place today, has led to huge shortages in staff, closures in programs and services, and unacceptable delays in care for veterans. As dozens of concerned VHA staff members have told the Prospect, the VAs ability to safely care for veteransand fulfill its Fourth Mission as a national backup system during health care emergenciesis being severely compromised by the HRM scheme.
Launched in 2018, Wilkies reorganization of human resources did not address the VAs longtime need for a streamlined and more decentralized hiring process, responsive to local workforce needs. Instead, local HR offices and staffreporting to health care facility directorswere almost entirely eliminated, replaced by a web-based system located far from local medical centers. HR now reports to the VA regional entities, known as Veterans Integrated Service Networks (VISNs), and ultimately VA central office in Washington.
The situation has become so dire that the VHA Chiefs of Staff Advisory Council conducted an internal survey to catalogue the consequences of the HR reorganization. This is a conservative group, not known to be rabble-rousers, as one source characterized them. The majority of chiefs of staff responded, and a whopping 92 percent said the HRM scheme had made things worse or much worse. Most said that the project had led to a tremendous drop in access to care. Another wrote, The current system could not be more dysfunctional and unhelpful if it tried.
The survey confirms what one director of a major VA medical center told the Prospect: This is an unmitigated disaster laid on top of another unmitigated disaster, the COVID-19 pandemic.
While this initiative was launched under the Trump administration, its been continued under the Biden administration. The modernization was led by Jessica Bonjorni, Wilkies chief of human capital management, who remains in charge of the continuing effort under his Biden-appointed successor, Denis McDonough.
According to accounts relayed to the Prospect, the new VA leadership has not responded to alarms from clinical and administrative leaders across the country. In a statement, VA spokesperson Terrence Hayes said: The length of time to hire new employees is among the top issues staff have raised to the Secretary when he visits VHA facilities, and he is committed to improving the process, the performance of which he believes is unacceptable.
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How could an organizational function as seemingly mundane as HR jeopardize the delivery of care by the Veterans Health Administration? Well, in the nations largest and most complex health care system, hiring, retaining, helping to educate, and in many other ways serving a workforce of 300,000 is no small job. Nor is it an easy one under current labor market conditions, where COVID-19 has created intense competition to hire health care personnel.
The VAs HR department is responsible for recruiting new staff, vetting their credentials, deciding what they will be paid, notifying candidates of the status of their job applications, and, if they are hired, onboarding them so they are ready to work. HR is also responsible for giving people merit raises, and getting them the identity cards that allow them access to patients and the VHA computer system. HR also deals with labor relations, applications for Family and Medical Leave, or for reassignment should they have an injury and be unable to do their current job, among other functions.
As the Prospect has previously written, and a report by the Veterans Healthcare Policy Institute confirmed, the VHAs HR system has long been overly cumbersome, creating needless hiring delays and other internal problems. Because of a prohibition against double encumberingor temporarily paying two people to do the same job, so the new recruit can learn from the departing employeeHR staff often wont begin the replacement process until a departing employee is literally out the door. Requests for new hires are often derailed by a complex approval process that can take months to greenlight. Then HR has to make sure candidates have the proper educational and licensing credentials and dont have criminal records, all of which is done sequentially rather than simultaneously. And all this is complicated by the fact that VA often cant meetand certainly cant exceedsalary offers made by private-sector health care employers.
Even with such obstacles in the past, the VHA could secure the necessary staff. As the former medical center director told us: When HR staff were located in my facility, I could expedite hiring and go down to HR and say I wanted this person A process that might ordinarily take months could sometimes be shortened to a period of a few weeks.
For nearly a year, VA clinical staff, medical directors, and chiefs of staff have alerted VA leaders in Washington about the severity of the impact of modernization on VHAs ability to deliver safe, quality care.
Imagine trying to find a suicide prevention coordinator in an online system when you cant explain to a real person how urgently you need these positions filled and they wont even respond to your emails, the former VHA director said. Facilities may be short 75 or 100 nurses. How can shortages like that even be allowed to exist?
The current director said that VHA could wait up to a year to get back to applicants. The VA disputes this, providing statistics to the Prospect that state the average time to hire for a clinical staff employee decreased to 94 days in the third quarter of 2021, down from 117 days in the second quarter of 2020. The vacancy rate for clinical staff is 7 percent, representing over 8,400 positions.
The survey from the Chiefs of Staff Advisory Council also indicated that HR staff didnt make offers in a timely fashion, which resulted in applicants finding other work. Delays in HR extending a formal offer, the survey notes, led to the annual loss to competing offers of 5 or more interested candidates in 69 percent of facilities and more than 10 candidates in 37 percent.
In one recent training session, newly appointed associate and assistant directors (who serve under a systems director) shared their concerns with Renee Oshinski, then the assistant undersecretary of health for operations under McDonough. Many participants felt that Oshinski didnt consider the matter to be very urgent and simply urged the group to be patient. According to one source, representatives of the Chiefs of Staff Advisory Council tried to meet with Bonjorni, but the latter reportedly demurred.
I met with the secretary and told him that I dont have the staffing, pay is too low to attract and retain people, the VHA medical center director told the Prospect. Its putting more work on people like service chiefs who are now trying to do HR functions.
According to the survey results, HRM problems have led to reductions in clinical services, closing of programs, reduction in clinical capacity, increased costs of community care, staff losses and demoralization of remaining staff who must shoulder an increasing clinical or administrative burden.
The VA disputes this, saying that net onboarding has increased year over year. Hayes said that the recruitment and retention challenges mirror the private sector and its staffing issues during the COVID-19 pandemic.
But the comments section of the report is even more damning. Repeatedly, chiefs reported bed closures due to lack of nursing staff, including a need to reduce inpatient mental-health beds because of staffing shortages, in the midst of a veteran suicide epidemic. The chiefs said the HR problem is so severe that it is even thwarting attempts to fill vacant positions among HR staff. The VA says that, as of the third quarter of 2021, there were 661 vacant HR positions, with a 9.7 percent vacancy rate.
Over and over again, chiefs said failures to hire resulted in the need to send more veterans to private-sector providers, which in the words of one chief are now saturated, and cannot take on more vets. Another warned that this is increasing the number of veterans who are dying due to lack of care from not being able to fill positions in a timely fashion.
The Chiefs of Staff released the survey in the hope that the data will convince top VA leaders about the extent and seriousness of the HR situation. This is a patient safety issue, one respondent begged. HELP US!!!
Interviews that the Prospect conducted with more than a dozen VA clinicians and directors confirmed the reports findings and conclusions. Pulmonologist Jason Kelley has been a clinician and chief of service at VHA medical centers in Kentucky and Vermont for 24 years. Throughout his career, hes worked with many of the VAs local human resources staff, but now, you cant reach anyone at the local level. Kelley told the Prospect that hes never had the volume of HR-related problems that he and his colleagues have experienced during the past three months.
Kelley describes the system as unresponsive. For example, we need to hire internists to serve as Medical Officer of the Day, he said. These people stay with us for only a short time but provide critical coverage for patients at night or in the emergency room. We select candidates, do the initial paperwork, get letters of recommendation and then, he paused and sighed, we have to wait for maybe six months for HR to do its part. HR cant even seem to do the most minor functions like making changes in an individual physicians status or processing approved merit pay.
Its absolutely abysmal, says a physician leader on the West Coast. It was always a challenge to get a position filled, now they have totally dismantled the whole HR process. You used to have contact with an HR person who could handle the problem. Now we have to use an anonymous email server group list. It now takes 6 to 12 months to hire. We couldnt even get PIV (Personal Identity Verification) cards with chips that let you access VA computers.
Prior to HRM, if a VHA facility needed a psychologist, a panel of psychologists would meet to vet the applicants for the job and decide who was the most qualified individual whod applied. One VA psychologist told the Prospect that now, these decisions are often made by HR staff who lack the qualifications necessary to decide who is or is not a qualified candidate.
Nurses are also very exercised about the HRM project. As one nurse union leader told the Prospect, If a nurse can no longer push beds around, and her doctor has confirmed the problem, she has to go through HR, and they are supposed to respond in 30 days. Now it takes months, and the nurse is forced to do that job or quit. Same thing is true with anyone who wants to take Family and Medical Leave. Nurses have become so frustrated with staffing shortages that those represented by the National Nurses United staged a protest rally in front of the Brooklyn VA Medical Center on January 13th.
VA leaders response to the COS report has so far not been reassuring. Sources have told the Prospect that when the Biden administrations acting deputy undersecretary for health, Steven L. Lieberman (the Biden administration has continued the Trump practice of failing to appoint a permanent undersecretary for health), was informed about the problems, he did not acknowledge any serious issues, expressed great faith in VA HR, and argued that some of the chiefs of staff participating in the survey were whiners.
Indeed, when the Prospect reached out to a chief of staff at a major VA medical center in the South, the chief feared being dismissed as a complainer for drawing attention to the HR problem, which would lead to even more HR centralization.
The VA said that leadership is committed to the success of HR Modernization and focuses efforts on improving VHAs time to hire, including through the establishment of project teams that are actively working on process improvements, system redesign, and HR information system enhancements to improve time to hire.
The first step to resolving the situation, experts say, is acknowledging that there is indeed a crisis. The next is to immediately assemble a high-level group to tackle it and quickly come up with solutions. That may involve decentralizing and returning some local control, and definitely improving local accountability.
Theres a difference between standardizing processes like how you verify that a physician actually has a medical license and applying one-size-fits-all processes to hiring, one longtime VA expert said. You have to have a system that combines standardized processes with the recognition that hiring a cardiologist in West Los Angeles is different than hiring one in Alabama.
Its been long recommended that VA seek expert advice from the National Academy of Public Administration (NAPA), a federally chartered group whose explicit mandate is to help government leaders solve their most critical management challenges. According to some former VA officials, NAPA has offered to assist on the HR issue, but has never been consulted.
It is heartening to hear that the VA is, according to the spokesperson, pursuing relief from pay caps and incentive caps for clinicians with Congressional support. Internally, VHA is also taking a close look at addressing burnout among the entire healthcare workforce. A burnout taskforce is evaluating recommendations from VHA facilities that include concerns about Time to Hire, staffing levels, and work-life scheduling flexibilities. All this work needs congressional support and to be accelerated.
This crisis is happening just as the non-VA health care system is currently staggering under successive waves of COVID-19 variants. Hospitals, clinics, physician practices, and nursing homes are all overwhelmed with patients and hampered by unprecedented staffing shortages that create intense competition for everything from cardiac surgeons to nursing home aides.
Veterans now depend, more than ever before, on the VHA. So do patients and staff in overwhelmed civilian facilities who rely increasingly on the VHAs Fourth Mission, to serve as backup to the non-VA system in times of national emergency. To quote one VA chief of staff, HR modernization is now an existential threat to VHA.