VA Health Care
Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists Gao ID: GAO-08-56 December 13, 2007Certified registered nurse anesthetists (CRNA), registered nurses who have completed a master's degree program in nurse anesthesia, provide the majority of anesthesia care veterans receive in VA medical facilities. While the demand for CRNAs is anticipated to increase, many CRNAs employed by VA--VA CRNAs--are nearing retirement eligibility age. Concerns have been raised about the challenges VA may face in maintaining its VA CRNA workforce. GAO (1) identified VA CRNA workforce challenges that VA medical facilities may experience related to VA CRNAs, (2) identified the key mechanisms that VA medical facilities can use to recruit and retain VA CRNAs, and (3) determined the extent to which facilities use the key mechanisms. To identify VA CRNA workforce challenges, GAO analyzed Web-based surveys it sent to VA chief anesthesiologists, VA human resources officers, and VA CRNAs, with survey response rates of 92, 85, and 76 percent, respectively. GAO also identified the key mechanisms VA medical facilities can use to recruit and retain VA CRNAs and the extent that these mechanisms are used.
Department of Veterans Affairs (VA) medical facilities have challenges in recruiting and retaining VA CRNAs for their workforce. About three-fourths of all VA medical facility chief anesthesiologists responding to GAO's survey reported that they had difficulty recruiting VA CRNAs. The challenge recruiting VA CRNAs has made it difficult to fill existing VA CRNA vacancies at VA medical facilities. Overall, 54 percent of VA medical facility chief anesthesiologists reported temporarily closing some operating rooms and 72 percent reported delaying some elective surgeries. VA's retention challenge comes from a projected substantial attrition rate. Based on the results of its survey, GAO projects that 26 percent of VA's CRNAs will either retire from or leave VA in the next 5 years. VA medical facility officials reported in GAO's survey that the recruitment and retention challenges are caused primarily by the low level of VA CRNA salaries when compared with CRNA salaries in local market areas. VA has three key mechanisms its medical facilities can use to recruit and retain VA CRNAs. VA medical facilities can give bonuses to VA CRNAs--recruitment, relocation, and retention bonuses. In addition, VA has education payment programs that provide funding to cover CRNA education costs. Finally, medical facilities can also use VA's locality pay system (LPS) to determine whether to adjust VA CRNA salaries to help the facilities remain competitive with CRNA salaries in local market areas. Each of the three key recruitment and retention mechanisms--bonuses, education payment programs, and VA's LPS--are used by some VA medical facilities. GAO found that in fiscal years 2005 or 2006, just over one-third of VA medical facilities that hired VA CRNAs gave recruitment bonuses. For VA medical facilities that have VA CRNAs, less than one-third gave retention bonuses in fiscal years 2005 or 2006. In addition, all VA CRNAs that applied for funds to attend a CRNA school or to offset their educational debt and were eligible received these funds in fiscal years 2005 and 2006. GAO also found that more than half of VA medical facilities used VA's LPS to determine whether to adjust VA CRNA salaries in 2005 and in 2006. However, in the eight VA medical facilities visited, GAO found that although the facilities used VA's LPS, the majority of them did not fully follow VA's LPS policy correctly in either 2005 or 2006. Officials at these facilities did not always know or were not aware of certain aspects of the LPS policy, and VA has not provided training on the LPS to VA medical facility officials since the policy was changed in 2001. As a result, VA medical facility officials have not received LPS training that reflects VA's current LPS policy, and accordingly, cannot ensure that VA CRNA salaries have been adjusted as needed to be competitive. Although VA is in the process of developing a Web-based training course for the LPS, the department has not established a time frame for finalizing the development and implementation of this training course.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-08-56, VA Health Care: Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
December 2007:
VA Health Care:
Many Medical Facilities Have Challenges in Recruiting and Retaining
Nurse Anesthetists:
VA Nurse Anesthetists:
GAO-08-56:
GAO Highlights:
Highlights of GAO-08-56, a report to congressional requesters.
Why GAO Did This Study:
Certified registered nurse anesthetists (CRNA), registered nurses who
have completed a master‘s degree program in nurse anesthesia, provide
the majority of anesthesia care veterans receive in VA medical
facilities. While the demand for CRNAs is anticipated to increase, many
CRNAs employed by VA”VA CRNAs”are nearing retirement eligibility age.
Concerns have been raised about the challenges VA may face in
maintaining its VA CRNA workforce. GAO (1) identified VA CRNA workforce
challenges that VA medical facilities may experience related to VA
CRNAs, (2) identified the key mechanisms that VA medical facilities can
use to recruit and retain VA CRNAs, and (3) determined the extent to
which facilities use the key mechanisms. To identify VA CRNA workforce
challenges, GAO analyzed Web-based surveys it sent to VA chief
anesthesiologists, VA human resources officers, and VA CRNAs, with
survey response rates of 92, 85, and 76 percent, respectively. GAO also
identified the key mechanisms VA medical facilities can use to recruit
and retain VA CRNAs and the extent that these mechanisms are used.
What GAO Found:
Department of Veterans Affairs (VA) medical facilities have challenges
in recruiting and retaining VA CRNAs for their workforce. About three-
fourths of all VA medical facility chief anesthesiologists responding
to GAO‘s survey reported that they had difficulty recruiting VA CRNAs.
The challenge recruiting VA CRNAs has made it difficult to fill
existing VA CRNA vacancies at VA medical facilities. Overall, 54
percent of VA medical facility chief anesthesiologists reported
temporarily closing some operating rooms and 72 percent reported
delaying some elective surgeries. VA‘s retention challenge comes from a
projected substantial attrition rate. Based on the results of its
survey, GAO projects that 26 percent of VA‘s CRNAs will either retire
from or leave VA in the next 5 years. VA medical facility officials
reported in GAO‘s survey that the recruitment and retention challenges
are caused primarily by the low level of VA CRNA salaries when compared
with CRNA salaries in local market areas.
VA has three key mechanisms its medical facilities can use to recruit
and retain VA CRNAs. VA medical facilities can give bonuses to VA
CRNAs”recruitment, relocation, and retention bonuses. In addition, VA
has education payment programs that provide funding to cover CRNA
education costs. Finally, medical facilities can also use VA‘s locality
pay system (LPS) to determine whether to adjust VA CRNA salaries to
help the facilities remain competitive with CRNA salaries in local
market areas.
Each of the three key recruitment and retention mechanisms”bonuses,
education payment programs, and VA‘s LPS”are used by some VA medical
facilities. GAO found that in fiscal years 2005 or 2006, just over one-
third of VA medical facilities that hired VA CRNAs gave recruitment
bonuses. For VA medical facilities that have VA CRNAs, less than one-
third gave retention bonuses in fiscal years 2005 or 2006. In addition,
all VA CRNAs that applied for funds to attend a CRNA school or to
offset their educational debt and were eligible received these funds in
fiscal years 2005 and 2006. GAO also found that more than half of VA
medical facilities used VA‘s LPS to determine whether to adjust VA CRNA
salaries in 2005 and in 2006. However, in the eight VA medical
facilities visited, GAO found that although the facilities used VA‘s
LPS, the majority of them did not fully follow VA‘s LPS policy
correctly in either 2005 or 2006. Officials at these facilities did not
always know or were not aware of certain aspects of the LPS policy, and
VA has not provided training on the LPS to VA medical facility
officials since the policy was changed in 2001. As a result, VA medical
facility officials have not received LPS training that reflects VA‘s
current LPS policy, and accordingly, cannot ensure that VA CRNA
salaries have been adjusted as needed to be competitive. Although VA is
in the process of developing a Web-based training course for the LPS,
the department has not established a time frame for finalizing the
development and implementation of this training course.
What GAO Recommends:
GAO recommends that VA expedite development and implementation of the
training course on VA‘s LPS policy for VA facility officials
responsible for compliance with the policy. VA generally concurred with
the conclusions and recommendation and stated that it had developed a
draft action plan.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-56]. For more information, contact Laurie
E. Ekstrand at (202) 512-7114 or ekstrandl@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
VA Medical Facilities Have VA CRNA Recruitment and Retention Challenges
Partly Because of Noncompetitive Salaries:
VA Can Offer Bonuses, Pay Education Costs, and Adjust Salaries to
Recruit and Retain VA CRNAs:
Some Medical Facilities Use the Key Recruitment and Retention
Mechanisms, Though in Some Cases LPS Was Used Incorrectly:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Analysis of GAO Survey of Certified Registered Nurse
Anesthetists Employed by VA:
Appendix III: Analysis of GAO Survey of Chief Anesthesiologists
Employed by VA:
Appendix IV: Analysis of GAO Survey of VA Medical Facility Human
Resources Officers:
Appendix V: Description of Education and Training Requirements for
Anesthesia Practitioners:
Appendix VI: Comments from the Department Of Veterans Affairs:
Appendix VII: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Reported Effects of VA CRNA Vacancies on Delivery of Services
at VA Medical Facilities:
Table 2: Reported Reasons VA Medical Facilities Used Contract CRNAs,
Fiscal Years 2005 and 2006:
Table 3: Differences in VA CRNA Salaries and CRNA Salaries in Local
Market Areas, as Reported by VA Chief Anesthesiologists, Fiscal Years
2005 and 2006:
Abbreviations:
AA: anesthesiologist assistant:
AANA: American Association of Nurse Anesthetists:
BLS: Bureau of Labor Statistics:
CRNA: certified registered nurse anesthetist:
DOD: Department of Defense:
EISP: Employee Incentive Scholarship Program:
EDRP: Education Debt Reduction Program:
HR: human resources:
HRRO: Healthcare Retention and Recruitment Office:
LPS: locality pay system:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
December 13, 2007:
The Honorable Daniel K. Akaka:
Chairman:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Ken Salazar:
United States Senate:
Certified registered nurse anesthetists (CRNA) provide the majority of
anesthesia care[Footnote 1] veterans receive in medical facilities
operated by the Department of Veterans Affairs (VA). CRNAs are
registered nurses who have completed a 2 to 3 year master's degree
program in nurse anesthesia and who typically provide anesthesia care
in health care settings with anesthesiologists and surgeons. There are
approximately 500 VA-employed CRNAs (VA CRNA) who provide anesthesia
care to veterans in VA medical facilities. The demand for CRNAs in VA
medical facilities has continued to increase because CRNAs are no
longer used only in the operating room, but are used in other areas of
a medical facility, such as administering anesthesia to patients who
are undergoing cardiac catheterization and providing airway management
to patients during cardiac emergencies.
While the demand for CRNAs is anticipated to increase, many VA CRNAs
are nearing retirement eligibility age. According to VA officials, more
than half of VA CRNAs are over the age of 51, and the average VA CRNA
is 7 years closer to retirement eligibility than the average CRNA
nationally. Because CRNAs provide the majority of anesthesia services
in VA medical facilities and facility officials have reported problems
with recruiting and retaining VA CRNAs, concerns have been raised about
the challenges VA may face in maintaining its VA CRNA workforce,
particularly in some local market areas where the labor market for
CRNAs can be highly competitive.
You asked that we review VA's efforts to recruit and retain VA CRNAs.
In this report, we (1) identify workforce challenges that VA medical
facilities may experience related to VA CRNAs, (2) identify the key
mechanisms that VA medical facilities can use to recruit and retain VA
CRNAs, and (3) determine the extent to which VA medical facilities use
the key mechanisms to recruit and retain VA CRNAs.
To identify workforce challenges VA medical facilities may experience
related to VA CRNAs, we analyzed data obtained from three of our Web-
based surveys. The first survey, administered to VA CRNAs, obtained a
response rate of 76 percent and allowed us to determine whether these
VA CRNAs plan to retire or leave VA's health care system within the
next 5 years. The second survey was administered to VA medical
facilities' chief anesthesiologists and obtained a 92 percent response
rate, and the third survey was administered to VA human resources (HR)
officers and obtained an 85 percent response rate. We used the second
and third surveys to identify the issues VA medical facilities face
when recruiting and retaining VA CRNAs. We also analyzed data on VA
CRNA vacancies--the number of unfilled VA CRNA positions at VA medical
facilities--obtained from VA headquarters. These data were from 2005,
the most recent year for which vacancy data were available.
Additionally, we obtained data on VA CRNAs' salaries for 2005, 2006,
and 2007 and compared these to salary data we obtained from the
American Association of Nurse Anesthetists (AANA), a professional
organization for CRNAs, to determine whether VA medical facilities'
salaries for VA CRNAs are competitive with CRNA salaries in local
market areas.[Footnote 2] We interviewed a representative from Kaiser
Permanente, a large health care plan that primarily uses CRNAs to
deliver anesthesia services, to identify what steps this health plan
takes to ensure it has a sufficient number of CRNAs and to determine
the indicators this plan uses to identify a CRNA shortage or potential
future CRNA shortage.
To ensure the reliability of the data we used, we interviewed VA and
AANA officials about the quality checks and edits they performed on
their data. In addition, we assessed the data obtained from our three
Web-based surveys by performing a systematic review of the returned
questionnaires. On the basis of our assessment we determined these data
were adequate for our purposes.
To determine the key mechanisms that VA medical facilities use to
recruit and retain VA CRNAs, we reviewed VA's policies and directives
related to VA CRNAs and obtained reports on VA CRNAs' salaries,
bonuses,[Footnote 3] education programs, and qualification standards.
We interviewed officials at VA headquarters and selected VA medical
facilities. To determine the extent to which VA medical facilities use
key mechanisms to recruit and retain VA CRNAs, we visited eight VA
medical facilities located in Denver, Colorado; Houston, Texas;
Minneapolis, Minnesota; New York, New York; Portland, Oregon; Seattle,
Washington; Tampa, Florida; and Togus, Maine. We selected these
facilities because they are geographically dispersed across the country
and employ VA CRNAs. At each VA medical facility we visited, we
interviewed chief anesthesiologists, VA CRNAs, HR officers, and other
facility officials and asked them about their efforts to recruit and
retain VA CRNAs. We also analyzed data obtained from our three Web-
based surveys to determine the extent to which VA medical facilities
use the key mechanisms to recruit and retain VA CRNAs. For a complete
description of our scope and methodology, see appendix I. The results
of our surveys are provided in appendixes II, III, and IV. We conducted
our work from June 2006 through October 2007 in accordance with
generally accepted government auditing standards.
Results in Brief:
VA medical facilities have challenges in recruiting and retaining VA
CRNAs for their workforce. About three-fourths of all VA medical
facility chief anesthesiologists responding to our survey reported that
they had difficulty recruiting VA CRNAs. The challenge recruiting VA
CRNAs has made it difficult to fill existing vacancies--or the number
of unfilled VA CRNA positions--at VA medical facilities. Overall, 54
percent of VA medical facility chief anesthesiologists reported
temporarily closing some operating rooms and 72 percent reported
delaying some elective surgeries. In addition, VA's retention challenge
comes from a projected substantial attrition rate. On the basis of our
survey results, we project that 26 percent of VA's CRNAs will either
retire from or leave VA in the next 5 years. While some facilities are
likely to experience substantially less than 26 percent attrition, many
others are likely to have to manage with much higher rates. VA medical
facility officials reported in our survey that the recruitment and
retention challenges are caused primarily by the low level of VA CRNA
salaries when compared with CRNA salaries in local market areas.
VA has three key mechanisms its medical facilities can use to recruit
and retain VA CRNAs. VA medical facilities can give bonuses to VA
CRNAs--recruitment, relocation, and retention bonuses. Each of these
bonuses can be up to 25 percent of a VA CRNA's salary, according to
VA's policy. Further, VA CRNAs who are receiving a recruitment or
relocation bonus are not eligible for a retention bonus while receiving
either of the other two types of bonuses, according to a VA official.
Additionally, VA has two education payment programs medical facilities
may use to help recruit and retain VA CRNAs. One program provides
funding to registered nurses for training to become a CRNA, and the
other provides funding to offset educational debt incurred by VA CRNAs.
Finally, medical facilities can use VA's locality pay system (LPS) to
determine whether to adjust VA CRNA salaries to help the facilities
remain competitive with CRNA salaries in local market areas.
Each of the three key recruitment and retention mechanisms--bonuses,
education payment programs, and VA's LPS are used by some VA medical
facilities. We found that in fiscal year 2005, of the 47 VA medical
facilities that hired VA CRNAs, 18 gave recruitment bonuses, and in
fiscal year 2006, 15 of 43 facilities that hired VA CRNAs gave
recruitment bonuses. In addition, less than one-third of VA medical
facilities that employ VA CRNAs gave retention bonuses. Specifically,
32 facilities gave retention bonuses in fiscal year 2005 and 36
facilities gave them in fiscal year 2006. Two facilities gave
relocation bonuses in fiscal year 2005 and 3 in fiscal year 2006. In
addition, all VA CRNAs that applied for funds to attend a CRNA school
or to offset their educational debt and were eligible received these
funds in fiscal years 2005 and 2006. We also found that more than half
of VA medical facilities that have VA CRNAs used VA's LPS to determine
whether to adjust VA CRNA salaries. However, in the 8 VA medical
facilities we visited, we found that although the facilities used VA's
LPS, the majority of them did not fully follow VA's LPS policy
correctly in either 2005 or 2006. Officials at these facilities did not
always know or were unaware of certain aspects of the LPS policy. VA
has not provided training on its policy to VA medical facility
officials since the policy was changed in 2001. As a result, VA medical
facility officials have not received LPS training that reflects VA's
current policy, and accordingly, cannot ensure that VA CRNA salaries
have been adjusted as needed to be competitive. Although VA is in the
process of developing a Web-based training course for LPS, the
department has not established a time frame for finalizing the
development and implementation of this training course.
To improve VA's ability to recruit and retain VA CRNAs, we recommend
that the Secretary of Veterans Affairs direct the Assistant Secretary
for Human Resources and Administration to expedite development and
implementation of the training course on VA's LPS policy for VA medical
facility officials responsible for compliance with the policy. In
commenting on a draft of this report, VA generally agreed with our
conclusions. VA also concurred with our recommendation to expedite the
development and implementation of the training course on VA's LPS
policy and stated that it has developed a draft action plan for
training staff on this policy and anticipates the on-line training
course will be available by the end of fiscal year 2008. VA also
provided technical comments, which we have incorporated as appropriate.
Background:
Anesthesia services are provided by anesthesia practitioners--
typically anesthesiologists and CRNAs. Anesthesiologists are physicians
who have completed medical school and typically a 4-year anesthesiology
residency. Both anesthesiologists and CRNAs administer anesthesia for
all types of surgical procedures, working either as single providers or
together. Anesthesia services can be provided by anesthesiologists
alone, by anesthesiologists working with CRNAs, by CRNAs alone, or by
anesthesiologist assistants (AA), working under the supervision of an
anesthesiologist. AAs are graduates of a medical- school-based AA
education program. (See app. V for the education and training
requirements for anesthesiologists, CRNAs, and AAs.)
The nurse anesthetist profession has made efforts to meet the demand
for CRNA services in the public and private health care sectors. The
profession has increased the number of accredited CRNA training
programs, and as a result the number of CRNA graduates has increased--
over 2,000 graduates in 2007, 57 percent more than in the year 2000.
The growth in the demand for CRNAs is expected to continue.
A joint Department of Defense (DOD)/VA program in nurse anesthesia
education was established in 2004 at Fort Sam Houston in San Antonio,
Texas. This 30-month program, run by the United States Army, educates
military personnel and VA registered nurses to become CRNAs. New VA
CRNAs who complete this program have a 3-year service obligation to VA
upon graduation.
When hiring VA CRNAs, VA places them in one of five pay grades, based
on the CRNA's education and experience. VA's qualification standards
for VA CRNAs establish the five grades with grade I being the lowest.
The grades ultimately determine the salary for each VA CRNA working in
a VA medical facility. Within each grade, there are a number of steps-
-generally 12--that represent progressive increments of a 3 percent
increase in salary within the grade. For example, the salary of a VA
CRNA that is at grade II, step 2, is 3 percent more than a VA CRNA's
salary at grade II, step 1. VA CRNA qualification standards indicate
that new graduate VA CRNAs usually begin at grade I, receiving a lower
salary because of the lack of work experience, whereas experienced VA
CRNAs might start at grade II or III receiving a higher salary. VA
medical facilities' salaries for a VA CRNA at a grade I, step 1, range
from a low of $37,432 to a high of $104,575 in market areas where
salaries are higher.
VA CRNAs typically work under the medical direction of a chief
anesthesiologist, who is responsible for supervising anesthesia
clinical staff, such as other anesthesiologists and nurse anesthetists.
Chief anesthesiologists are responsible for the quality and safety of
anesthesia services provided in the medical facility. VA CRNA benefits
and other personnel issues, such as hiring and setting base salaries,
are managed by VA medical facilities' HR officers. HR officers are also
responsible for issues related to compensation, employee and labor
relations, recruitment, and performance management.
VA medical facilities have clinical staff that are trained to provide
different types of health care services. In many cases, the ability to
provide health care services to veterans is dependent on the
availability of numerous types of clinical staff that work in concert
with one another to provide these services. If one of these types of
staff is not available, the health care service may be delayed or not
provided. For example, even though a CRNA is available to provide
anesthesia services, if other personnel, such as operating room nurses
or nurses that staff the post-anesthesia recovery unit, are not
available, the surgical procedure may be delayed or cancelled.
Likewise, if a CRNA, or other professional anesthesia staff, are not
available, the surgical procedure may have to be delayed or cancelled.
VA Medical Facilities Have VA CRNA Recruitment and Retention Challenges
Partly Because of Noncompetitive Salaries:
VA medical facilities have challenges recruiting and retaining VA
CRNAs. Most surveyed officials reported that they had difficulty
recruiting VA CRNAs at their facilities. The challenge recruiting VA
CRNAs affects the ability of VA officials to reduce existing VA CRNA
vacancy rates--the number of unfilled VA CRNA positions--at their
medical facilities. These rates vary across VA, with 26 medical
facilities having vacancy rates of 25 percent or more and 15 of them
having vacancy rates of 40 percent or more.[Footnote 4] Overall, 54
percent of the chief anesthesiologists responding to our survey
reported temporarily closing some operating rooms and 72 percent
reported delaying some elective surgeries because of VA CRNA vacancies
in fiscal year 2006. On the basis of our survey results, in addition to
their current recruiting challenges, VA medical facilities will likely
face a challenge retaining VA CRNAs in the next 5 years due to the
number of VA CRNAs projected to either retire from or leave VA. VA
medical facility officials reported in our survey that the recruitment
and retention challenges are caused primarily by the low level of VA
CRNA salaries when compared with CRNA salaries in local market areas.
VA Officials Report Challenges Recruiting CRNAs, and Projected VA CRNA
Attrition Will Create a Retention Challenge in the Next 5 Years:
Our survey results indicate that VA medical facilities have a challenge
recruiting VA CRNAs. Of all VA medical facility chief anesthesiologists
that responded to our survey, 74 percent reported that they had
difficulty recruiting CRNAs in fiscal years 2005 and 2006. The
recruiting challenges also affect VA medical facility officials'
ability to reduce existing VA CRNA vacancy rates at their medical
facilities. Additionally, VA medical facility officials responding to
our survey reported that it takes VA facilities a long time--on average
about 15 months--to fill a VA CRNA vacancy from the time facility
management approval is granted to fill the position until the time the
VA CRNA actually begins providing services at the facility. In
particular, VA chief anesthesiologists at 11 medical facilities
reported that their facilities took 2 years or more on average to fill
a VA CRNA vacancy. In our survey, the shortest time taken to fill a
vacancy as reported by the chief anesthesiologists was 2 months, and
the longest was 60 months.
The challenge of recruiting CRNAs limits the ability of VA officials to
reduce existing vacancy rates at their medical facilities. VA's fiscal
year 2005 vacancy data[Footnote 5] show VA had about a 13 percent VA
CRNA vacancy rate systemwide, or 70 unfilled VA CRNA positions at 43
medical facilities.[Footnote 6] These rates vary across VA, with 26
medical facilities having vacancy rates of 25 percent or more and 15 of
them having vacancy rates of 40 percent or more in fiscal year 2005.
According to the director of Kaiser Permanente's school of anesthesia
for nurse anesthetists, a vacancy rate of 40 percent or higher is
considered indicative of a staffing problem. Like VA's vacancy data,
our survey also suggests that VA CRNA vacancies are common across VA
medical facilities. Of the chief anesthesiologists responding to our
survey, 54 percent reported that they had VA CRNA vacancies at their VA
medical facility, with the number of VA CRNA vacancies ranging from one
to six.
According to our survey, VA CRNA vacancies have impacted the delivery
of services at VA medical facilities. For example, 54 percent of the VA
chief anesthesiologists with VA CRNA vacancies reported that they
temporarily closed operating rooms, 72 percent delayed elective
surgeries, and 68 percent increased the use of overtime for VA CRNAs,
as a result of VA CRNA vacancies in fiscal year 2006. Moreover, 44
percent of chief anesthesiologists that had VA CRNA vacancies reported
that contract CRNAs were used.[Footnote 7] In addition, almost one-
third of the chief anesthesiologists whose vacancies were filled
reported that they still had a shortage of VA CRNAs. See table 1 for
the types of effects that VA CRNA vacancies have had on the delivery of
services, as reported by chief anesthesiologists who reported VA CRNA
vacancies.
Table 1: Reported Effects of VA CRNA Vacancies on Delivery of Services
at VA Medical Facilities:
Type of effects that VA CRNA vacancies have had on delivery of
services: Some elective surgeries were delayed;
Percentage of chief anesthesiologists reporting type of effect: 72.
Type of effects that VA CRNA vacancies have had on delivery of
services: VA CRNA overtime increased;
Percentage of chief anesthesiologists reporting type of effect: 68.
Type of effects that VA CRNA vacancies have had on delivery of
services: Some operating rooms were closed temporarily;
Percentage of chief anesthesiologists reporting type of effect: 54.
Type of effects that VA CRNA vacancies have had on delivery of
services: Contract CRNAs were used;
Percentage of chief anesthesiologists reporting type of effect: 44.
Type of effects that VA CRNA vacancies have had on delivery of
services: Other effects[A];
Percentage of chief anesthesiologists reporting type of effect: 34.
Type of effects that VA CRNA vacancies have had on delivery of
services: Some patients were diverted to other facilities;
Percentage of chief anesthesiologists reporting type of effect: 32.
Type of effects that VA CRNA vacancies have had on delivery of
services: Intermittent or fee-basis CRNAs were used[B];
Percentage of chief anesthesiologists reporting type of effect: 30.
Type of effects that VA CRNA vacancies have had on delivery of
services: No effect on the medical facility;
Percentage of chief anesthesiologists reporting type of effect: 2.
Source: GAO survey of VA medical facility chief anesthesiologists.
Note: Chief anesthesiologists may have reported more than one effect
that VA CRNA vacancies have on the delivery of services.
[A] A few of the other effects cited by the chief anesthesiologists
include anesthesiologists working overtime or through their lunch hour,
the use of contract anesthesiologists, and general staff
dissatisfaction.
[B] Intermittent CRNAs are those that work at VA on an irregular or
occasional basis and whose hours or days of work are not on a
prearranged schedule and they are paid only for the hours actually
worked. Fee-basis CRNAs are those that work at VA on a limited basis
and are paid per procedure and not on an hourly rate.
[End of table]
According to some VA chief anesthesiologists who responded to our
survey, the use of contract CRNAs has increased over the last 3 years.
In fiscal years 2005 and 2006, about 30 percent of VA medical facility
chief anesthesiologists who responded to our survey reported using
contract CRNAs to supplement their anesthesia workforce. See table 2
for the reasons cited by chief anesthesiologists for using contract
CRNAs. These chief anesthesiologists reported on our survey that they
used an average of less than one full-time contract CRNA in both fiscal
years 2005 and 2006. According to our survey, the chief
anesthesiologists who reported data for both contract hours and
contract costs reported a median hourly CRNA contract cost of $112 in
fiscal year 2005 and $114 in fiscal year 2006.[Footnote 8] This
compares to an hourly cost for a full-time VA CRNA of $82 in fiscal
year 2005 and $84 in fiscal year 2006 for a VA CRNA earning the maximum
statutory salary.[Footnote 9]
Table 2: Reported Reasons VA Medical Facilities Used Contract CRNAs,
Fiscal Years 2005 and 2006:
Reasons VA medical facilities used contract CRNAs: Difficulty
recruiting VA CRNAs;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 52;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 45.
Reasons VA medical facilities used contract CRNAs: Shortage of CRNAs in
the local market area;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 41;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 39.
Reasons VA medical facilities used contract CRNAs: Difficulty retaining
VA CRNAs;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 27;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 30.
Reasons VA medical facilities used contract CRNAs: Short-term coverage
for a VA CRNA's absence;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 32;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 27.
Reasons VA medical facilities used contract CRNAs: Other reasons;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 16;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 16.
Reasons VA medical facilities used contract CRNAs: Coverage for a VA
CRNA called to active military duty;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 16;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 9.
Reasons VA medical facilities used contract CRNAs: Retirement of a VA
CRNA;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 14;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 14.
Reasons VA medical facilities used contract CRNAs: Higher than
anticipated surgical volume;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 14;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 11.
Reasons VA medical facilities used contract CRNAs: Higher than
anticipated VA CRNA vacancy rate;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 9;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 11.
Reasons VA medical facilities used contract CRNAs: Hiring freeze;
Percentage of chief anesthesiologists reporting reason in fiscal year
2005: 5;
Percentage of chief anesthesiologists reporting reason in fiscal year
2006: 2.
Source: GAO survey of VA medical facility chief anesthesiologists.
Note: Chief anesthesiologists may have reported more than one reason
why contract CRNAs were used.
[End of table]
In addition to the current challenges of recruiting CRNAs, VA medical
facilities are also likely to face another workforce challenge in the
future. Specifically, in the next 5 years VA medical facilities will
likely have difficulty retaining VA CRNAs in their workforce and this
trend could increase the number of VA CRNA vacancies across VA. On the
basis of VA CRNA responses to our survey, we project a VA CRNA
attrition rate of 26 percent across VA in the next 5 years--that is, 26
percent of VA CRNAs either plan to retire or leave VA's health care
system within the next 5 years.[Footnote 10] Overall, 93 VA CRNAs at 53
of VA's 120 medical facilities that employ VA CRNAs reported that they
plan to retire or leave VA's health care system. While the overall
projected attrition rate across VA, on the basis of our survey results,
is likely to be 26 percent, this rate will vary by medical facility. In
27 VA medical facilities, we project that the attrition rate is likely
to be 50 percent or higher. According to the director of Kaiser
Permanente's school of anesthesia for nurse anesthetists, an attrition
rate of 50 percent or higher is considered indicative of a future
staffing problem.
According to VA Officials and VA CRNAs, Difficulty Recruiting and
Retaining VA CRNAs is Due to Noncompetitive VA CRNA Salaries:
Our surveys of VA medical facility chief anesthesiologists and HR
officers indicate that medical facilities have trouble recruiting and
will have trouble retaining VA CRNAs because salaries for VA CRNAs are
low compared to CRNA salaries in local market areas. Of the 69 chief
anesthesiologists who reported having difficulty recruiting VA CRNAs
during fiscal years 2005 and 2006, about 60 of them attributed this
difficulty primarily to the fact that salaries for VA CRNAs at their
medical facilities were not competitive with CRNA salaries in local
market areas.[Footnote 11] Additionally, of the 46 chief
anesthesiologists who reported having difficulty retaining VA CRNAs
during fiscal years 2005 and 2006, 36 of them attributed this primarily
to the fact that salaries for experienced VA CRNAs[Footnote 12] at
their medical facilities were not competitive with CRNA salaries in
local market areas. Other reasons most frequently cited by the chief
anesthesiologists were indirectly associated with the level of VA CRNA
salaries.[Footnote 13]
Of the chief anesthesiologists surveyed, 72 percent (67) of chief
anesthesiologists reported that VA CRNA starting salaries for new
graduates at their facility were lower than local market area salaries
in fiscal year 2005, and 69 percent (64) of chiefs reported this in
fiscal year 2006. In fiscal years 2005 and 2006, 79 percent (73) of
chief anesthesiologists estimated that salaries for experienced VA
CRNAs at their medical facility were lower than local market area CRNA
salaries.
Furthermore, about 40 percent of chief anesthesiologists also reported
that salaries for both new graduate and experienced VA CRNAs at their
facility were $10,000 to $30,000 lower than CRNAs salaries in local
market areas during fiscal years 2005 and 2006. See table 3 for the
differences in VA CRNA salaries and CRNA salaries in local market areas
in fiscal years 2005 and 2006, as reported by VA chief
anesthesiologists.
Table 3: Differences in VA CRNA Salaries and CRNA Salaries in Local
Market Areas, as Reported by VA Chief Anesthesiologists, Fiscal Years
2005 and 2006:
VA CRNA salaries lower than CRNA salaries in local market areas by
$10,000 or less;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
New graduate VA CRNA[A]: 12;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
Experienced VA CRNA[B]: 13;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
New graduate VA CRNA[A]: 9;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
Experienced VA CRNA[B]: 12.
VA CRNA salaries lower than CRNA salaries in local market areas by
$10,001 to $30,000;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
New graduate VA CRNA[A]: 41;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
Experienced VA CRNA[B]: 40;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
New graduate VA CRNA[A]: 42;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
Experienced VA CRNA[B]: 42.
VA CRNA salaries lower than CRNA salaries in local market areas by more
than $30,000;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
New graduate VA CRNA[A]: 19;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
Experienced VA CRNA[B]: 26;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
New graduate VA CRNA[A]: 18;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
Experienced VA CRNA[B]: 23.
Not checked[C];
Percentage of chief anesthesiologists reporting for fiscal year 2005:
New graduate VA CRNA[A]: 8;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
Experienced VA CRNA[B]: 3;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
New graduate VA CRNA[A]: 9;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
Experienced VA CRNA[B]: 7.
Not applicable[D];
Percentage of chief anesthesiologists reporting for fiscal year 2005:
New graduate VA CRNA[A]: 20;
Percentage of chief anesthesiologists reporting for fiscal year 2005:
Experienced VA CRNA[B]: 18;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
New graduate VA CRNA[A]: 23;
Percentage of chief anesthesiologists reporting for fiscal year 2006:
Experienced VA CRNA[B]: 17.
Source: GAO survey of VA medical facility chief anesthesiologists.
Note: Column totals may not add to 100 percent due to rounding and not
all chief anesthesiologists who reported salaries were lower specified
how much lower.
[A] New graduate VA CRNAs have less than 2 years experience.
[B] Experienced VA CRNAs have 2 or more years of experience.
[C] Represents the chief anesthesiologists who did not provide a
response to this question.
[D] Represents the chief anesthesiologists who reported that VA CRNA
salaries were not lower than the local market area.
[End of table]
Although the majority--about 79 percent--of VA medical facility chief
anesthesiologists reported that VA CRNA salaries are not competitive
with local market CRNA salaries, less than half of VA medical facility
HR officers who responded to our survey concurred. Our survey results
for new graduates and experienced VA CRNAs showed that in fiscal years
2005 and 2006 about 45 percent of HR officers reported that their
facilities' starting salaries for new graduate VA CRNAs were low when
compared with CRNA salaries in local market areas.[Footnote
14],[Footnote 15] In addition, about 47 percent of HR officers reported
that salaries for experienced VA CRNAs were low when compared with CRNA
salaries in local market areas in fiscal years 2005 and 2006. Further,
our survey asked HR officers to report how much lower VA salaries were
than local market area salaries for new graduate and experienced VA
CRNAs. Our survey results showed that 17 percent of HR officers
reported that salaries for new graduate VA CRNAs were $10,001 to
$30,000 lower than CRNAs' salaries in local market areas in fiscal
years 2005 and 2006. Also, about 19 percent of HR officers reported
that salaries for experienced VA CRNAs were $10,001 to $30,000 lower
than CRNAs' salaries in local market areas in both fiscal years.
Furthermore, of the VA CRNAs who responded to our survey, 69 percent
(250) of VA CRNAs reported that higher starting salaries for new
graduate CRNAs would strengthen VA's recruitment efforts.[Footnote 16]
When VA CRNAs who are considering retirement were asked what would make
them postpone retirement, 91 percent (94) reported that higher salaries
would delay their retirement from a VA medical facility. In addition,
when VA CRNAs who are not eligible to retire in the next 5 years were
asked what would keep a VA CRNA from leaving VA, 82 percent (119) of VA
CRNAs reported that a higher salary would keep them working at
VA.[Footnote 17]
A VA headquarters official acknowledged that some medical facilities
currently face recruitment challenges related to VA CRNA salaries. This
official stated that according to anecdotal reports, there are CRNA
recruiting challenges in some local market areas, while in other market
areas there are no problems with recruitment. To address this problem,
VA CRNAs and the director of VA's anesthesia services told us they are
revising VA CRNA qualification standards, which will have the effect of
increasing starting salaries for new graduate VA CRNAs from grade I to
grade II. However, this revision to VA CRNA qualification standards--
increase in grade and resulting starting salary--would be unlikely to
make most VA CRNA starting salaries competitive with local market area
CRNA starting salaries. We compared VA CRNA 2007 salary schedules to
projected AANA 2007 salary data to determine whether VA CRNA salaries
would be competitive with local market area CRNA salaries if salaries
for new graduate VA CRNAs were changed from grade I to grade II. Our
analysis showed that this revision to VA CRNA qualification standards
will not make most VA CRNA starting salaries competitive with local
market area starting CRNA salaries. Specifically, 75 of 120 VA medical
facilities that employ VA CRNAs would have VA CRNA starting salaries
below local market area CRNA salaries by $20,000 or more.
Similar challenges exist related to the retention of VA CRNAs. More
than half of all VA CRNAs earned the maximum statutory salary
cap[Footnote 18] for a VA CRNA in 2006, which was $133,900. However, at
107 of VA's 120 medical facilities that employ VA CRNAs this maximum
statutory salary cap is at least $20,000 lower than CRNA salaries in
local market areas, based on our analysis comparing AANA salary data
for CRNAs to VA's maximum statutory salary cap of $133,900. According
to VA officials, VA has proposed legislation to increase the maximum
statutory salary cap. The proposal would increase the maximum statutory
salary cap for VA CRNAs by about $9,000. Our analysis comparing AANA
salary data for CRNAs to VA's CRNA maximum statutory salary cap
indicated that increasing the VA CRNA maximum statutory salary cap by
about $9,000 will not, at a majority of VA medical facilities, make VA
CRNA salaries competitive with CRNA salaries in local market areas.
Specifically, we found that after the proposed change, 70 of the 120 VA
medical facilities' VA CRNA salaries would still be $20,000 or more
below the local market area CRNA salaries.[Footnote 19]
VA Can Offer Bonuses, Pay Education Costs, and Adjust Salaries to
Recruit and Retain VA CRNAs:
VA has three key mechanisms its medical facilities can use to recruit
and retain VA CRNAs. VA medical facilities can award recruitment,
relocation, and retention bonuses of up to 25 percent of a VA CRNA's
salary, according to VA's policy. Additionally, VA has two education
payment programs medical facilities may use to help recruit and retain
VA CRNAs. One program provides funding to registered nurses for
training to become a CRNA, and the other provides funding to offset
educational debt incurred by VA CRNAs. Finally, medical facilities can
use VA's LPS to determine whether to adjust VA CRNA salaries to help
the facilities remain competitive with CRNA salaries in local market
areas.
VA Medical Facilities Can Use Bonuses to Recruit and Retain VA CRNAs:
VA medical facilities can use two types of bonuses--recruitment and
relocation--to recruit VA CRNAs, and another type of bonus--retention-
-to retain VA CRNAs.[Footnote 20] Recruitment, relocation, and
retention bonuses can be used to recruit and retain employees in
positions that are difficult to fill, such as VA CRNAs. VA's policy
allows medical facility officials to approve bonuses up to 25 percent
of VA CRNAs' salaries for each year the VA CRNA agrees to work for the
VA medical facility. Before approving a bonus, medical facility
officials are required to document that certain criteria have been met,
such as whether the facility is having difficulty recruiting and
retaining VA CRNAs, whether the facility's VA CRNA salaries are
competitive with CRNA salaries in local market areas, or whether the
facility has a high VA CRNA turnover rate.[Footnote 21] VA medical
facilities may terminate an agreement to pay a recruitment, relocation,
or retention bonus if this payment does not meet the needs of VA, such
as a lack of medical facility funds. Medical facility directors have
discretion to determine whether to pay a bonus to VA CRNAs.
To receive a recruitment bonus, a VA CRNA must agree to work a minimum
of 6 months and the bonus may be given for a maximum service period of
4 years. There is a great deal of flexibility in paying out this bonus,
according to VA officials. Facility officials can choose to pay all or
part of the bonus up front or split the bonus over any number of pay
periods. VA medical facilities have authority to use a recruitment
bonus if they are likely to have difficulty recruiting VA CRNAs.
VA CRNAs may receive a relocation bonus to entice them to relocate to
the area where the VA medical facility is located. To receive this
bonus, a VA CRNA must agree to work a minimum of 6 months. Relocation
bonuses are given to CRNAs who must change their job sites and
physically relocate to a different geographic area.
A retention bonus may be given to a VA CRNA for an unlimited service
period and is paid out after the service period is completed if paid on
any basis other than biweekly. VA medical facilities may give a
retention bonus if a special need exists for the VA CRNA's services and
it is likely that the VA CRNA will resign without the bonus. VA CRNAs
who are receiving a recruitment or relocation bonus are not eligible
for a retention bonus while receiving either of the other two types of
bonuses, according to a VA HR official.
Two VA Education Payment Programs Allow Medical Facilities to Provide
Funding to Cover CRNA Education Costs to Recruit and Retain VA CRNAs:
Medical facilities also have two VA education payment programs to aid
in recruiting and retaining VA CRNAs--VA's Employee Incentive
Scholarship Program (EISP) and VA's Education Debt Reduction Program
(EDRP). VA's Healthcare Retention and Recruitment Office (HRRO) manages
these two programs.[Footnote 22] VA's EISP was established in March
2000 and is a scholarship program for VA registered nurses who attend
CRNA training programs.[Footnote 23] These registered nurses are
eligible for an EISP scholarship after a minimum of 1 year of
continuous VA employment. VA's student CRNAs can use EISP funding to
pay for the cost of their tuition, books, and for other related
educational expenses, such as registration and fees. Additionally, EISP
covers half of the salary of a registered nurse to replace the CRNA
student and the other half is paid by the VA medical facility where the
student will work once the CRNA training program is completed. VA CRNA
students may use EISP funds to attend the joint DOD/VA nurse anesthesia
training program. In fiscal year 2006, the lifetime maximum amount of a
scholarship that could be paid to a VA CRNA through EISP was $35,024,
and the VA CRNA then had a service obligation to VA for 3 years.
VA's EDRP, a student loan repayment program established in May 2002, is
available to newly hired clinicians, such as VA CRNAs, and is used as a
recruitment tool by VA medical facilities. In fiscal year 2006, the
maximum amount that could be paid to a VA CRNA for EDRP was $38,000
divided into annual payments over a 5-year period.
The distribution of funds for both EISP and EDRP varies by medical
facility and is contingent upon the availability of VA funds.
Applicants must be recommended by the medical facility director and
approved by HRRO. VA medical facility selection criteria for both EISP
and EDRP include an individual's career goals, work performance,
workforce needs of VA, and a recommendation from an immediate
supervisor.
Medical Facilities Can Adjust VA CRNA Salaries Using VA's LPS:
While VA CRNA grades, which establish VA CRNA salaries, are initially
determined by VA's qualification standards for VA CRNAs, VA medical
facilities have the option of adjusting these salaries to recruit and
retain VA CRNAs.[Footnote 24] When adjusting VA CRNA salaries, VA
medical facilities are required to use a process known as LPS.[Footnote
25] The system is intended to help VA medical facilities determine
whether to adjust VA CRNA salaries to be regionally competitive. VA's
LPS supports these goals by providing information on salaries paid to
CRNAs in a facility's local market area. To collect data for the LPS,
medical facility directors, who are responsible for their facility's
LPS, can either use a salary survey conducted by another entity or
conduct their own survey in order to determine the CRNA salary levels
paid by health care establishments in the local market area. VA's LPS
policy requires that a medical facility director initiate an LPS survey
if the director determines that a significant pay-related staffing
problem exists or is likely to exist for any occupation or specialty.
VA's LPS policy instructs medical facilities to use a survey conducted
by the Bureau of Labor Statistics (BLS); however, if data from this
survey are not available or not current, facilities are to use a third-
party locality pay survey. Third-party surveys include those that are
purchased from a third-party service that collects compensation data on
salaries of health care occupations. These surveys can also include
salary data collected by local hospital associations for their member
health care establishments. When BLS or other third-party surveys are
not available or do not contain sufficient salary data, facilities are
to conduct their own locality pay survey.
Under VA's LPS policy, a third-party locality pay survey must include
data from at least three non-VA health care establishments, such as
hospitals and outpatient clinics. VA's LPS policy requires that a third-
party survey cover an appropriate local market area, which is defined
by VA as one that includes the county in which the VA medical facility
is located and includes health care establishments that compete for the
same type of clinical employees, such as CRNAs. The health care
establishments that participate in a third-party survey should provide
job descriptions that include the duties, responsibilities, and
education and experience requirements of CRNAs and should be able to be
readily job-matched to VA's description of the VA CRNA grade levels.
If a VA medical facility conducts its own LPS survey, VA's LPS policy
requires that the geographic area surveyed be defined. In order to be
valid, three health care establishments must have job descriptions for
CRNAs that can be job-matched to VA CRNA grade levels. A VA medical
facility may expand the geographic area surveyed when the surveyed area
will not adequately reflect the local market area salaries for CRNAs or
there are less than three job matches.[Footnote 26]
Once the survey is completed, a facility's HR officer reports the
results to the medical facility director and based on the survey data,
recommends whether to adjust VA CRNA salaries. The facility director
makes the final decision on whether to adjust VA CRNA salaries and,
therefore, may choose not to adjust existing salaries regardless of
what the survey data show, according to VA's policy. VA medical
facility directors consider the competing demands for funding across
the facility when making decisions about VA CRNA salary increases.
VA's LPS policy requires VA medical facilities to report annually to VA
headquarters on VA CRNA staffing, such as the vacancy and turnover
rates for VA CRNAs within the recent fiscal year. VA medical facilities
are also required to report whether the facility had a pay-related
staffing problem as determined by the medical facility director and
whether a medical facility director used a locality pay survey to
determine if VA CRNA salaries should be adjusted. VA reported that in
2005 and 2006 all VA medical facility directors who determined that a
significant pay-related staffing problem existed or was likely to exist
at their facility used a locality pay survey to determine whether VA
CRNA salaries should be adjusted.
Some Medical Facilities Use the Key Recruitment and Retention
Mechanisms, Though in Some Cases LPS Was Used Incorrectly:
Each of the three key recruitment and retention mechanisms--bonuses,
education payment programs, and VA's LPS--are used by some VA medical
facilities. We found in fiscal years 2005 or 2006, of those VA medical
facilities that hired VA CRNAs, just over one-third gave recruitment
bonuses. In addition, less than one-third of all VA medical facilities
that employ VA CRNAs gave retention bonuses, and a few gave relocation
bonuses. We also found, according to data we obtained from VA, that all
who applied and were eligible for EISP and EDRP funds for CRNA training
received these funds. Further, more than half of the VA medical
facilities responding to our survey reported using VA's LPS in 2005 and
in 2006 to determine whether to adjust VA CRNA salaries. However, five
of the eight VA medical facilities we visited did not fully follow VA's
LPS policy in either 2005 or 2006, and officials at these facilities
did not appear to understand certain aspects of the policy. These
problems indicate VA has not provided adequate training on the LPS
process since the policy was changed in 2001.
Some VA Medical Facilities Give Bonuses to VA CRNAs:
According to VA data, of the 47 VA medical facilities that hired a VA
CRNA in fiscal year 2005, 18 of these facilities paid recruitment
bonuses. Five facilities gave recruitment bonuses of $15,000 or more,
seven gave recruitment bonuses of between $10,000 and $14,999, and five
gave recruitment bonuses of less than $10,000. One facility gave
recruitment bonuses in two of the categories--the more than $15,000 and
less than $15,000 categories. In fiscal year 2006, of the 43 VA medical
facilities that hired a VA CRNA, 15 of these facilities paid
recruitment bonuses. Five facilities gave recruitment bonuses of
$15,000 or more, six gave recruitment bonuses of between $10,000 and
$14,999, and three gave recruitment bonuses of less than $10,000. One
facility gave recruitment bonuses in two of the categories--the more
than $15,000 and less than $10,000 categories. According to VA HR
officers who responded to our survey, facilities gave recruitment
bonuses to VA CRNAs because VA CRNA salaries at VA facilities were
lower than local market area salaries.
According to VA data, 32 and 36 VA medical facilities gave retention
bonuses to VA CRNAs in fiscal years 2005 and 2006, respectively. The
majority of these facilities gave a retention bonus of $10,000 or more.
According to more than one-fourth of VA medical facility HR officers
who responded to our survey, retention bonuses are used to make VA CRNA
salaries competitive with CRNA salaries in local market areas.
Compared with recruitment and retention bonuses, relocation bonuses are
less frequently used by VA medical facilities. According to VA data,
two VA medical facilities paid relocation bonuses of about $31,000 in
fiscal year 2005 to two VA CRNAs. In fiscal year 2006, VA data show
that three VA medical facilities gave relocation bonuses to four VA
CRNAs, with three bonuses ranging from $8,000 to $10,000, and one bonus
of $25,000.
VA Medical Facilities Use VA's Education Payment Programs for Nurse
Anesthetist Training:
VA medical facilities use VA's education payment programs, EISP and
EDRP, to expand the VA CRNA workforce. According to data we obtained
from VA, from March 2000 through September 2006, 25 VA registered
nurses at various medical facilities that were enrolled in nurse
anesthetist training programs applied for and were awarded EISP
scholarships. For fiscal years 2005 and 2006, 13 registered nurses
received EISP scholarships, of which 8 attended the joint DOD/VA CRNA
training program. Two of the eight VA medical facilities we visited had
approved an EISP award for students attending the joint DOD/VA CRNA
training program.
In addition to the EISP scholarships, VA CRNAs may be eligible for VA's
EDRP funds. VA data show that seven VA CRNAs applied for and were
approved to receive tuition reimbursement through the EDRP in fiscal
year 2005, and in fiscal year 2006, three VA CRNAs applied and were
approved to receive this funding. Two of the eight VA medical
facilities we visited had approved a total of three EDRP awards. At one
of these facilities, officials told us that they had remaining EDRP
funds in fiscal year 2006 because there were no employee applications,
so these funds were not used. VA medical facility officials determine
which occupations have priority in receiving EDRP funds based on
difficulty in recruiting these occupations.
A Majority of Medical Facilities Use VA's LPS to Determine Whether to
Adjust VA CRNA Salaries, but Instances of Incorrect Use Indicate
Inadequate Training on LPS Policy:
According to VA's 2005 data, 86 VA medical facilities that employ VA
CRNAs used VA's LPS to determine whether to adjust salaries of VA CRNAs
at their facilities. Of those that used VA's LPS, 63 facilities used a
third-party survey to obtain data on local market area salary rates for
CRNAs.
While VA's data showed that a majority of VA medical facilities that
employ VA CRNAs are using VA's LPS, we found that five of the eight
facilities we visited did not use the LPS in accordance with VA's LPS
policy in 2005 or 2006. The policy is designed to ensure that facility
officials have a mechanism to determine whether their VA CRNA salaries
should be adjusted to be competitive in recruiting and retaining VA
CRNAs. By not fully following this policy, officials at these five
facilities are making decisions to adjust or not adjust VA CRNA
salaries without sufficient data on the salaries of CRNAs in their
local market areas.
At the five VA medical facilities that did not fully follow VA's LPS
policy correctly, facility officials with oversight responsibility for
the LPS were not knowledgeable about certain aspects of the LPS policy.
One facility official told us that the third-party salary survey data
were determined to be insufficient, so the facility used salary data
from a Hot Jobs Web site to determine whether to adjust VA CRNA
salaries. The official was unaware that this data source cannot be
considered valid survey data for the purpose of adjusting VA CRNA
salaries. At one facility, officials applied an outdated methodology
for adjusting VA CRNA salaries and in doing so did not fully follow the
most current LPS policy. The outdated policy only permitted VA medical
facility officials to adjust salary rates for each VA CRNA grade at 5
percent above or below the beginning CRNA salary rates in local market
areas. In contrast, VA's current LPS policy allows facility officials
to adjust these salaries in order to be competitive. The remaining
three facilities did not have sufficient salary data to determine
whether VA CRNA salaries should be adjusted, and believed they could
not use salary data of CRNAs that work for organizations that contract
CRNA anesthesia services. These officials were unaware that VA's policy
allows them to expand their data collection to include this type of
salary data if the data they had previously collected were
insufficient.
The problems some VA medical facilities had fully following VA's LPS
policy, along with the explanations of facility officials, indicate
that VA has not provided adequate training on its LPS policy.
Currently, VA medical facility officials can refer to VA's LPS policy
when they have questions, or they can contact VA headquarters,
according to a VA official. VA last changed its LPS policy in 2001,
which resulted in a number of changes, such as the use of third-party
surveys and the use of salary data of CRNAs that work for organizations
that contract anesthesia services. VA, however, has not conducted
nationwide training on its LPS policy since 1995.[Footnote 27] As a
result, VA medical facility officials have not received LPS training
that reflects VA's current LPS policy, and accordingly, cannot ensure
that VA CRNA salaries have been adjusted as needed to be competitive.
VA is in the process of developing a Web-based training course for the
LPS that VA medical facility officials can complete on-line. VA is
early in the development of this project because it is assigned to two
staff that have other job priorities, according to a VA official.
Because VA has not made the training a priority, it has not established
a time frame for finalizing the development and implementation of this
training course.
Conclusions:
VA's difficulty recruiting and retaining VA CRNAs has created workforce
challenges that the department must confront now and in the future.
Because a significant number of VA CRNAs plan to retire or leave VA's
health care system in the next 5 years and because many VA medical
facilities do not have salaries that attract CRNAs, some VA medical
facilities may face significant challenges delivering anesthesia
services to veterans. It is important that VA maximize its ability to
recruit and retain VA CRNAs. A key mechanism VA medical facilities have
is the LPS, which is used to help facilities determine to what extent
VA CRNA salaries are competitive with the CRNA salaries paid by
competing health care establishments.
While the LPS is used across VA, at five of eight facilities we visited
officials used it incorrectly and appeared unaware of some of the
policy requirements related to the LPS. The lapses at the five
facilities reveal a larger problem: VA has not taken the necessary
steps to ensure that VA officials are aware of the current LPS policy
and can use it correctly. VA last provided training on the LPS in 1995,
but since then some aspects of the policy have changed. While VA has
indicated that it is developing Web-based training on the LPS, VA has
not made the development of this training a priority or indicated when
the training will be available. Current training on the LPS is
necessary to help ensure that VA medical facilities are competitive as
an employer by allowing medical facility officials to make salary
decisions for VA CRNAs with sufficient information on the CRNA salaries
in their local market areas.
Recommendation for Executive Action:
To improve VA's ability to recruit and retain VA CRNAs, we recommend
that the Secretary of Veterans Affairs direct the Assistant Secretary
for Human Resources and Administration to expedite development and
implementation of the training course on VA's LPS policy for VA medical
facility officials responsible for compliance with the policy.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, VA generally agreed with our
conclusions. VA also concurred with our recommendation to expedite the
development and implementation of the training course on VA's LPS
policy and stated that it has developed a draft action plan for
training staff on this policy and anticipates the on-line training
course will be available by the end of fiscal year 2008. VA provided
technical comments, which we have incorporated as appropriate.
VA expressed reservations about our reliance on information obtained
from VA CRNAs and VA chief anesthesiologists who responded to our
surveys. VA stated that those being surveyed may have inflated their
perceptions of recruitment and retention challenges with the hope that
findings may encourage additional resources for their professions. We
recognize there is a potential for bias in self-reported data; however,
we used other information to corroborate our survey findings.
Specifically, we also used information obtained from interviews with VA
headquarters officials, as well as survey data obtained from VA medical
facilities' human resources officers.
VA expressed concern about our projected VA CRNA attrition rate. On the
basis of VA CRNAs who reported they would retire or leave the VA within
the next 5 years, we projected a 26 percent attrition rate of VA CRNAs
systemwide. We anticipate that this rate will vary by VA medical
facility, with some facilities having a rate of 50 percent or higher
and others having a much lower rate. In commenting on our projected VA
CRNA attrition rate, VA noted that the 26 percent attrition rate
indicated that the VA CRNA turnover rate during the 5 years would
average 5.2 percent annually and that this turnover rate was low
compared to VA's actual turnover rate for VA CRNAs, which has ranged
from a low of 10.02 percent to a high of 15.6 percent.
VA also commented that our report highlighted the fact that more than
50 percent of VA CRNAs are over 51 years of age and nearing the
retirement eligibility age, implying that VA is at risk of losing a
significant number of VA CRNAs to retirement. VA stated that these VA
CRNAs are not necessarily retirement eligible or inclined to retire
when eligible. This information was included in the report with other
demographic information about VA CRNAs to provide some prospective on
VA's CRNA workforce. VA's written comments are reprinted in appendix
VI.
We are sending copies of this report to the Secretary of Veterans
Affairs and other interested parties. We will also provide copies to
others upon request. In addition, the report is available at no charge
on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (202) 512-7114 or at Ekstrandl@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
can be found on the last page of this report. GAO staff members who
made major contributions to this report are listed in appendix VII.
Signed by:
Laurie E. Ekstrand:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
We examined the Department of Veterans Affairs' (VA) certified
registered nurse anesthetists (CRNA) workforce issues and the
mechanisms that VA medical facilities use to recruit and retain VA
employed CRNAs (VA CRNA). Specifically, we (1) identified workforce
challenges that VA medical facilities may experience related to VA
CRNAs, (2) identified the key mechanisms that VA medical facility
officials can use to recruit and retain VA CRNAs, and (3) determined
the extent to which VA medical facilities use the key mechanisms to
recruit and retain VA CRNAs.
To identify workforce challenges that VA medical facilities experience
related to VA CRNAs, we analyzed data from our three Web-based surveys,
which captured information from fiscal years 2005 and 2006. Each of the
three surveys contained questions that helped us identify current and
future challenges that VA medical facilities will experience in
recruiting and retaining VA CRNAs. The first survey was administered in
December 2006 to 474 VA CRNAs. We contacted officials at all VA medical
facilities to determine whether they employed VA CRNAs both on a full-
time or part-time basis, and for those that did, obtained e-mail
addresses for the VA CRNAs. We verified our list of VA CRNAs with a
list obtained from VA's Personnel Accounting Integrated Data system,
which houses VA's payroll and human resources (HR) information. This
survey of VA CRNAs covered various workforce issues, including their
plans to retire or leave VA's health care system, the use of contract
CRNAs to supplement VA CRNAs, and recruitment and retention of VA
CRNAs. The survey had an overall response rate of 76 percent, which
allowed us to generalize to the VA CRNA population. The second survey
was administered in May 2007 to 125 chief anesthesiologists working in
the VA medical system.[Footnote 28] We obtained the contact list for
chief anesthesiologists from VA headquarters anesthesia services. This
survey covered CRNA workforce issues, including VA CRNA salaries,
staffing, recruitment and retention, the effect of vacancies on medical
facilities' services, and the use of contract CRNAs. The survey had an
overall response rate of 92 percent, which allowed us to generalize to
all VA medical facilities that employ VA CRNAs. The third survey was
administered in May 2007 to HR officers at 170 VA medical
facilities.[Footnote 29] We obtained the contact list for VA HR
officers from VA. The survey covered CRNA workforce issues including
salary, locality pay surveys, and bonuses given for recruitment and
retention. This survey had an overall response rate of 85 percent,
which allowed us to generalize to all VA medical facilities that employ
VA CRNAs. We also obtained VA medical facility data on the number of VA
CRNA vacancies and VA CRNA vacancy rates. These data are reported by VA
medical facilities to VA headquarters and were included in VA's 2006
annual report to Congress on staffing.
Additionally, we obtained VA CRNA salary schedules for 2005, 2006, and
2007 from VA headquarters for each VA medical facility. These salary
schedules contained the VA CRNA salary rates for grades I through V and
steps 1 to 12 for each of the grades. Using these salary schedules, we
compared VA CRNA salaries with CRNA salary data we obtained from the
American Association of Nurse Anesthetists (AANA), a professional
organization for CRNAs. AANA's salary data for CRNAs was compiled in
its 2006 Practice Profile Survey--a national survey of AANA's
membership--and included self-reported 2005 salary information that was
reported by state.[Footnote 30] To compare salaries for 2006 and 2007,
we projected the 2005 AANA salary data using the Bureau of Labor
Statistics (BLS) employment cost index.[Footnote 31] According to VA
officials, VA is seeking legislation that would increase VA CRNAs'
maximum statutory salary cap.[Footnote 32] On the basis of this
proposed legislation, we used VA's 2007 VA CRNA maximum statutory
salary cap that was $136,200 and would increase to $145,400 with the
proposed legislation. We compared VA's proposed increase to AANA's 2007
salary data for each state in which a VA medical facility is located to
determine whether increasing VA's maximum statutory salary cap as VA
proposes would make VA CRNA salaries competitive with local market area
salaries. We used the 90th percentile AANA CRNA salary in each state
for this comparison because this percentile represents the higher end
of the salary range for the local market area. In addition, we compared
VA CRNA qualification standards to VA's proposed revision, which would
increase starting salaries for new graduate VA CRNAs from grade I to
grade II. We compared 2007 VA CRNA salary schedules at the grade II
level for each facility to AANA's CRNA salary data for each state in
which a VA medical facility is located to determine whether grade II
salaries would be competitive with local market area salaries. We used
the 25th percentile AANA salary in each state for this comparison
because this percentile represents the lower end of the salary range
for the local market area.
We interviewed the director of Kaiser Permanente's school of anesthesia
for nurse anesthetists to identify what steps this director takes to
ensure it has a sufficient number of CRNAs to deliver anesthesia
services and to learn the indicators used to identify a CRNA shortage
or potential future shortage. We also interviewed the director of VA
headquarters anesthesia services to obtain information on VA CRNA
workforce challenges.
To determine the key mechanisms that VA medical facilities use to
recruit and retain VA CRNAs, we reviewed VA's policies and directives
related to VA CRNAs and obtained reports on VA CRNA salaries. We also
reviewed and analyzed policies, legislation, and regulations on VA's
locality pay system (LPS), and VA's authority to give recruitment,
relocation, and retention bonuses to VA CRNAs. In addition, we reviewed
legislation and policies related to two VA employee education programs-
-the Employee Incentive Scholarship Program (EISP) and the Education
Debt Reduction Program (EDRP). We interviewed officials at VA
headquarters, including HR officers. We interviewed chief
anesthesiologists, VA CRNAs, HR officers, and other officials at
selected VA medical facilities. We also interviewed officials from VA's
Healthcare Retention and Recruitment Office (HRRO), located in New
Orleans, Louisiana, to obtain information about the implementation of
EISP and EDRP.
To determine the extent to which VA medical facilities use the key
mechanisms to recruit and retain VA CRNAs, we analyzed data from our
three Web-based surveys. We analyzed data included in VA's 2006 annual
report to Congress on staffing, which included information on each VA
medical facility's use of LPS. We also obtained data from VA
headquarters on the number and amount of recruitment, relocation, and
retention bonuses paid to VA CRNAs in fiscal years 2005 and 2006.
Additionally, we obtained data from VA's HRRO on funds distributed to
VA medical facilities for the EISP and EDRP.
To gain further information on the extent to which VA medical
facilities use the key mechanisms, we visited eight VA medical
facilities. We selected these facilities to obtain anecdotal examples,
which are supported by our data collection. The findings from these
eight facilities cannot be generalized to all VA medical facilities. We
also selected the facilities based on geographical variation and
because they employed VA CRNAs. The eight VA medical facilities we
visited are located in Denver, Colorado; Houston, Texas; Minneapolis,
Minnesota; New York, New York; Portland, Oregon; Seattle, Washington;
Tampa, Florida; and Togus, Maine. At each medical facility, we
interviewed chief anesthesiologists, VA CRNAs, HR officers, and other
facility officials. In addition, we obtained copies of locality pay
surveys for 2005 and 2006 from the eight medical facilities.
We obtained data from VA headquarters and AANA and surveyed VA CRNAs,
VA chief anesthesiologists, and VA HR officers. Data obtained from VA
headquarters included CRNA salaries for each VA medical facility by VA
CRNA grade and step, medical facility VA CRNA vacancy rates, and type
of VA CRNA locality pay survey used at each VA medical facility. We
also obtained from VA headquarters data from its Personnel Accounting
Integrated Data (PAID) system that contained the amounts of individual
VA CRNA recruitment, relocation, and retention bonuses. We contacted VA
officials responsible for these data sets to gain an understanding of
the completeness and accuracy of the data VA headquarters provided and
whether quality checks were performed by VA on these data. In addition,
we obtained 2005 salary data from AANA as reported in their members'
annual survey. We interviewed AANA officials to determine the quality
checks they performed on the data from this survey. The AANA members'
survey has an overall response rate of 60 percent and has had a similar
response rate for the last 25 years. AANA noted that the income data
from the survey is self reported by AANA members and in some of the
smaller states the number of respondents was small. We also conducted
Web-based surveys of VA CRNAs, VA chief anesthesiologists, and VA HR
officers to identify workforce challenges that VA medical facilities
experience related to VA CRNAs. A systematic review of the returned
questionnaires was performed, checking for factors such as key
questions being answered, skip patterns being followed, written entries
clearly entered, and quantitative entries within scope. On the basis of
our assessment of the reliability and limitations of VA headquarters'
data, AANA members' survey data, and our three Web-based surveys, we
determined that the data used in this report were adequate for our
purposes.
We conducted our work from June 2006 through October 2007 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II Analysis of GAO Survey of Certified Registered Nurse
Anesthetists Employed by VA:
To obtain the views of VA CRNAs on various recruitment and retention
issues, we conducted a Web-based survey of all VA CRNAs employed at VA
medical facilities. The questionnaire contained questions on topics
such as CRNAs' views on recruitment and retention incentives, use of
contract/agency CRNAs at the medical facility where they work, and the
CRNAs' plans to leave the VA medical facility in the next 5 years. Not
all column totals will add to 100 percent due to rounding, multiple
answers to questions that ask respondents to check all that apply, and
no response by VA CRNAs to some questions.
Table: Q1. Of the factors listed, which five factors attracted you to
work at this VA medical facility?
1. Salary;
Checked (percentage): 26.6;
Number of respondents: 361.
2. Recruitment incentive;
Checked (percentage): 10.3;
Number of respondents: 361.
3. Relocation incentive;
Checked (percentage): 3.9;
Number of respondents: 361.
4. Promotion potential;
Checked (percentage): 4.4;
Number of respondents: 361.
5. Reimbursement for continuing education;
Checked (percentage): 5.0;
Number of respondents: 361.
6. VA's education debt reduction;
Checked (percentage): 9.4;
Number of respondents: 361.
7. Retirement benefits;
Checked (percentage): 67.6;
Number of respondents: 361.
8. Leave benefits (annual and sick);
Checked (percentage): 64.0;
Number of respondents: 361.
9. Flexible work schedule;
Checked (percentage): 23.0;
Number of respondents: 361.
10. Broader scope of practice;
Checked (percentage): 49.9;
Number of respondents: 361.
11. Complexity of surgical cases;
Checked (percentage): 33.2;
Number of respondents: 361.
12. Working with/supervising student CRNAs;
Checked (percentage): 17.7;
Number of respondents: 361.
13. Job security;
Checked (percentage): 48.8;
Number of respondents: 361.
[End of table]
Table: Q2. Of the factors listed, which five factors keep you working
at this VA medical facility?
1. Salary;
Checked (percentage): 25.0;
Number of respondents: 361.
2. Retention incentive;
Checked (percentage): 14.4;
Number of respondents: 361.
3. Promotion potential;
Checked (percentage): 1.1;
Number of respondents: 361.
4. Reimbursement for continuing education;
Checked (percentage): 6.1;
Number of respondents: 361.
5. VA's education debt reduction;
Checked (percentage): 5.8;
Number of respondents: 361.
6. Retirement benefits;
Checked (percentage): 71.8;
Number of respondents: 361.
7. Leave benefits (annual and sick);
Checked (percentage): 63.2;
Number of respondents: 361.
8. Flexible work schedule;
Checked (percentage): 25.8;
Number of respondents: 361.
9. Broader scope of practice;
Checked (percentage): 36.8;
Number of respondents: 361.
10. Complexity of surgical cases;
Checked (percentage): 28.0;
Number of respondents: 361.
11. Working with/supervising student CRNAs;
Checked (percentage): 19.1;
Number of respondents: 361.
12. Job security;
Checked (percentage): 45.2;
Number of respondents: 361.
[End of table]
Table: Q3. Are you eligible to retire now or within the next 5 years?
1. Yes, I am eligible to retire now;
Checked (percentage): 10.0;
Number of respondents: 361.
2. Yes, I am eligible to retire within the next 5 years;
Checked (percentage): 26.0;
Number of respondents: 361.
3. No;
Checked (percentage): 64.0;
Number of respondents: 361.
[End of table]
Table: Q4. If you are eligible or when you become eligible, do you plan
to retire?
1. Yes;
Checked (percentage): 43.9;
Number of respondents: 130.
2. No;
Checked (percentage): 20.8;
Number of respondents: 130.
3. Don't know;
Checked (percentage): 35.4;
Number of respondents: 130.
[End of table]
Table: Q5. Of the factors listed, which three factors would encourage
you to postpone retiring?
1. Higher salary;
Checked (percentage): 91.3;
Number of respondents: 103.
2. Shorten the number of years to advance to the next grade level;
Checked (percentage): 11.7;
Number of respondents: 103.
3. More monetary awards;
Checked (percentage): 47.6;
Number of respondents: 103.
4. Reimbursement for continuing education;
Checked (percentage): 30.1;
Number of respondents: 103.
5. Feeling valued;
Checked (percentage): 35.0;
Number of respondents: 103.
6. Broader scope of practice;
Checked (percentage): 12.6;
Number of respondents: 103.
7. More involvement in decisions involving this VA medical facility's
anesthesia services;
Checked (percentage): 35.0;
Number of respondents: 103.
[End of table]
Table: Q6. After you retire from the federal government, do you plan to
work as a CRNA outside of VA's health care system?
1. Yes;
Checked (percentage): 60.2;
Number of respondents: 103.
2. No;
Checked (percentage): 10.7;
Number of respondents: 103.
3. Don't know;
Checked (percentage): 28.2;
Number of respondents: 103.
[End of table]
Table: Q7. Do you plan to leave this VA medical facility within the
next 5 years?
1. Yes, to work for another VA medical facility;
Checked (percentage): 4.7;
Number of respondents: 232.
2. Yes, to leave VA's health care system;
Checked (percentage): 15.5;
Number of respondents: 232.
3. No;
Checked (percentage): 37.5;
Number of respondents: 232.
4. Don't know;
Checked (percentage): 37.1;
Number of respondents: 232.
[End of table]
Table: Q8. Of the factors listed, which three factors not currently
available at this VA medical facility would keep you working here?
1. Higher salary;
Checked (percentage): 81.5;
Number of respondents: 146.
2. Shorten the number of years to advance to the next grade level;
Checked (percentage): 13.0;
Number of respondents: 146.
3. More monetary awards;
Checked (percentage): 32.2;
Number of respondents: 146.
4. Reimbursement for continuing education;
Checked (percentage): 34.9;
Number of respondents: 146.
5. Greater availability of VA's education debt reduction program funds;
Checked (percentage): 10.3;
Number of respondents: 146.
6. Feeling valued;
Checked (percentage): 26.7;
Number of respondents: 146.
7. Broader scope of practice;
Checked (percentage): 13.0;
Number of respondents: 146.
8. More involvement in decisions involving this VA medical facility's
anesthesia services;
Checked (percentage): 24.0;
Number of respondents: 146.
[End of table]
Table: Q9. Has this VA medical facility used contract/agency CRNAs
during the last 2 years (from October 1, 2004 through September 30,
2006)?
1. Yes;
Checked (percentage): 47.7;
Number of respondents: 361.
2. No;
Checked (percentage): 46.8;
Number of respondents: 361.
3. Don't know;
Checked (percentage): 5.0;
Number of respondents: 361.
[End of table]
Table: Q10. Is there a shortage of CRNAs at this VA medical facility?
1. Yes;
Checked (percentage): 65.4;
Number of respondents: 361.
2. No;
Checked (percentage): 28.8;
Number of respondents: 361.
3. Don't know;
Checked (percentage): 5.3;
Number of respondents: 361.
[End of table]
Table: Q11. Of the factors listed, which five factors would strengthen
recruitment of CRNAs at this VA medical facility?
1. Higher salaries for CRNAs with experience;
Checked (percentage): 90.9;
Number of respondents: 361.
2. Higher salaries for new CRNA graduates;
Checked (percentage): 69.3;
Number of respondents: 361.
3. Shorten the number of years to advance to the next grade level;
Checked (percentage): 36.0;
Number of respondents: 361.
4. Using more recruitment incentives;
Checked (percentage): 39.1;
Number of respondents: 361.
5. Higher recruitment incentives;
Checked (percentage): 31.3;
Number of respondents: 361.
6. Greater availability of VA's education debt reduction program funds;
Checked (percentage): 26.9;
Number of respondents: 361.
7. Reimbursement for continuing education;
Checked (percentage): 52.1;
Number of respondents: 361.
8. Timely hiring practices;
Checked (percentage): 45.4;
Number of respondents: 361.
9. Ability to quote a firm starting salary prior to hiring a CRNA;
Checked (percentage): 44.6;
Number of respondents: 361.
10. Broader scope of practice for VA CRNAs;
Checked (percentage): 19.7;
Number of respondents: 361.
[End of table]
[End of section]
Appendix III: Analysis of GAO Survey of Chief Anesthesiologists
Employed by VA:
To obtain the views of VA's chief anesthesiologists on various
recruitment and retention issues, we conducted a Web-based survey of
all VA chief anesthesiologists employed at VA medical facilities. The
questionnaire contained questions on topics, such as the chief
anesthesiologists' views on CRNA recruitment and retention issues; CRNA
vacancies, the effects of the vacancies, and the time it takes to fill
CRNA vacancies; whether CRNA salaries at VA medical facilities are
competitive with CRNA salaries in local market areas; and the use of
contract CRNAs. Not all column totals will add to 100 percent due to
rounding, multiple answers to questions that ask respondents to check
all that apply, and no response by VA chief anesthesiologists to some
questions.
Table: Q1. How many months on average did it take to fill a vacant VA
CRNA position from the time the request to fill the vacancy was
approved to the time the vacancy was filled?
Months: 2;
Checked (percentage): 2.3;
Number of respondents: 43.
Months: 3;
Checked (percentage): 7.0;
Number of respondents: 43.
Months: 4;
Checked (percentage): 2.3;
Number of respondents: 43.
Months: 5;
Checked (percentage): 4.7;
Number of respondents: 43.
Months: 6;
Checked (percentage): 16.3;
Number of respondents: 43.
Months: 8;
Checked (percentage): 2.3;
Number of respondents: 43.
Months: 9;
Checked (percentage): 7.0;
Number of respondents: 43.
Months: 10;
Checked (percentage): 2.3;
Number of respondents: 43.
Months: 11;
Checked (percentage): 4.7;
Number of respondents: 43.
Months: 12;
Checked (percentage): 14.0;
Number of respondents: 43.
Months: 14;
Checked (percentage): 2.3;
Number of respondents: 43.
Months: 18;
Checked (percentage): 7.0;
Number of respondents: 43.
Months: 20;
Checked (percentage): 2.3;
Number of respondents: 43.
Months: 24;
Checked (percentage): 16.3;
Number of respondents: 43.
Months: 36;
Checked (percentage): 4.7;
Number of respondents: 43.
Months: 42;
Checked (percentage): 2.3;
Number of respondents: 43.
Months: 60;
Checked (percentage): 2.3;
Number of respondents: 43.
[End of table]
Table: Q2. What were the effects on this facility of having VA CRNA
vacancies?
1. Some operating rooms were closed temporarily;
Checked (percentage): 54.0;
Number of respondents: 50.
2. Some patients were diverted to other facilities;
Checked (percentage): 32.0;
Number of respondents: 50.
3. Some elective surgeries were delayed;
Checked (percentage): 72.0;
Number of respondents: 50.
4. VA CRNA overtime increased;
Checked (percentage): 68.0;
Number of respondents: 50.
5. Contract CRNAs were used;
Checked (percentage): 44.0;
Number of respondents: 50.
6. Intermittent, per diem, and /or fee-basis CRNAs were used;
Checked (percentage): 30.0;
Number of respondents: 50.
7. No effect;
Checked (percentage): 2.0;
Number of respondents: 50.
[End of table]
Table: Q3. As of September 30, 2006, did this facility have a shortage
of CRNAs even though all its VA CRNA allocated positions were filled?
1. Yes;
Checked (percentage): 29.0;
Number of respondents: 93.
2. No;
Checked (percentage): 39.8;
Number of respondents: 93.
3. Don't know;
Checked (percentage): 31.2;
Number of respondents: 93.
[End of table]
Table: Q4. What were the effects on this facility of having a shortage
of VA CRNAs?
1. Some operating rooms were closed temporarily;
Checked (percentage): 28.6;
Number of respondents: 56.
2. Some patients were diverted to other facilities;
Checked (percentage): 3.6;
Number of respondents: 56.
3. Some elective surgeries were delayed;
Checked (percentage): 35.7;
Number of respondents: 56.
4. VA CRNA overtime increased;
Checked (percentage): 30.4;
Number of respondents: 56.
5. Contract CRNAs were used;
Checked (percentage): 16.1;
Number of respondents: 56.
6. Intermittent, per diem, and /or fee-basis CRNAs were used;
Checked (percentage): 12.5;
Number of respondents: 56.
7. No effect;
Checked (percentage): 0;
Number of respondents: 56.
[End of table]
Table: Q5. Has this facility had any difficulty in recruiting CRNAs in
the last 2 years (October 1, 2004 - September 30, 2006)?
1. Yes;
Checked (percentage): 74.2;
Number of respondents: 93.
2. No;
Checked (percentage): 25.8;
Number of respondents: 93.
[End of table]
Table: Q6. What are the reasons this facility has had difficulties in
recruiting CRNAs?
(Continued From Previous Page)
1. Salary level for new graduate VA CRNAs is low compared to the local
market area;
Checked (percentage): 88.4;
Number of respondents: 69.
2. Salary level for experienced VA CRNAs is low compared to the local
market area;
Checked (percentage): 85.5;
Number of respondents: 69.
3. Recruitment incentives are not available;
Checked (percentage): 29.0;
Number of respondents: 69.
4. Recruitment incentives are not sufficient;
Checked (percentage): 46.4;
Number of respondents: 69.
5. Tuition reimbursement is not available;
Checked (percentage): 29.0;
Number of respondents: 69.
6. Tuition reimbursement is not sufficient;
Checked (percentage): 18.8;
Number of respondents: 69.
7. Reimbursement for continuing education expenses is not available;
Checked (percentage): 33.3;
Number of respondents: 69.
8. Reimbursement for continuing education expenses is not sufficient;
Checked (percentage): 34.8;
Number of respondents: 69.
9. Shortage of CRNAs in the local market area;
Checked (percentage): 66.7;
Number of respondents: 69.
10. Lengthy hiring process;
Checked (percentage): 71.0;
Number of respondents: 69.
11. Inability to make salary offer promptly;
Checked (percentage): 53.6;
Number of respondents: 69.
12. Inability to hire new CRNAs prior to them passing their boards;
Checked (percentage): 14.5;
Number of respondents: 69.
[End of table]
Table: Q7. Has this facility had difficulty with VA CRNAs leaving or
with retaining VA CRNAs in the last 2 years (October 1, 2004-September
30, 2006)?
1. Yes, difficulty with VA CRNAs leaving;
Checked (percentage): 12.9;
Number of respondents: 93.
2. Yes, difficulty with retaining VA CRNAs;
Checked (percentage): 14.0;
Number of respondents: 93.
3. Both - difficulty with VA CRNAs leaving and with retaining VA CRNAs;
Checked (percentage): 22.6;
Number of respondents: 93.
4. No;
Checked (percentage): 50.5;
Number of respondents: 93.
[End of table]
Table: Q8. What are the reasons this facility has had difficulty with
VA CRNAs leaving or with retaining VA CRNAs?
(Continued From Previous Page)
1. Salary level for new graduate VA CRNAs is low compared to the local
market area;
Checked (percentage): 45.7;
Number of respondents: 46.
2. Salary level for experienced VA CRNAs is low compared to the local
market area;
Checked (percentage): 78.3;
Number of respondents: 46.
3. Retention incentive is not available;
Checked (percentage): 21.7;
Number of respondents: 46.
4. Retention incentive is not sufficient;
Checked (percentage): 47.8;
Number of respondents: 46.
5. Reimbursement for continuing education expenses is not available;
Checked (percentage): 26.1;
Number of respondents: 46.
6. Reimbursement for continuing education expenses is not sufficient;
Checked (percentage): 32.6;
Number of respondents: 46.
7. Scope of practice includes complex procedures not routinely
performed by CRNAs in non-VA facilities;
Checked (percentage): 8.7;
Number of respondents: 46.
8. Scope of practice does not include complex procedures not routinely
performed by CRNAs in non-VA facilities;
Checked (percentage): 0;
Number of respondents: 46.
[End of table]
Table: Q9. How did VA CRNA annual salaries at this facility generally
compare with local market area CRNA salaries from October 1, 2004-
September 30, 2005 for new graduate CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 4.3;
Number of respondents: 93.
2. VA CRNA salaries were lower;
Checked (percentage): 72.0;
Number of respondents: 93.
3. VA CRNA salaries were commensurate;
Checked (percentage): 6.5;
Number of respondents: 93.
4. Don't know;
Checked (percentage): 14.0;
Number of respondents: 93.
[End of table]
Table: Q10. How did VA CRNA annual salaries at this facility generally
compare with local market area CRNA salaries from October 1, 2004-
September 30, 2005 for experienced CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 4.3;
Number of respondents: 93.
2. VA CRNA salaries were lower;
Checked (percentage): 78.5;
Number of respondents: 93.
3. VA CRNA salaries were commensurate;
Checked (percentage): 9.7;
Number of respondents: 93.
4. Don't know;
Checked (percentage): 7.5;
Number of respondents: 93.
[End of table]
Table: Q11. If this facility's 2005 VA CRNA salaries were higher than
local market area salaries, how much higher were the salaries for new
graduate CRNAs?
1. $5,000 or less;
Checked (percentage): 1.1;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 1.1;
Number of respondents: 93.
3. $10,001 to $20,000;
Checked (percentage): 1.1;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 1.1;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 1.1;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 0;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 62.4;
Number of respondents: 93.
[End of table]
Table: Q.12. If this facility's 2005 VA CRNA salaries were higher than
local market area salaries, how much higher were the salaries for
experienced CRNAs?
1. $5,000 or less;
Checked (percentage): 0;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 2.2;
Number of respondents: 93.
3. $10,001 to $20,000;
Checked (percentage): 1.1;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 2.2;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 0;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 1.1;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 0;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 61.3;
Number of respondents: 93.
[End of table]
Table: Q13. If this facility's 2005 VA CRNA salaries were lower than
local market area salaries, how much lower were the salaries for new
graduate CRNAs?
1. $5,000 or less;
Checked (percentage): 2.2;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 9.7;
Number of respondents: 93.
3. $10,001 to $20,000;
Checked (percentage): 17.2;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 23.7;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 10.8;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 4.3;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 4.3;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 20.4;
Number of respondents: 93.
[End of table]
Table: Q14. If this facility's 2005 VA CRNA salaries were lower than
local market area salaries, how much lower were the salaries for
experienced CRNAs?
1. $5,000 or less;
Checked (percentage): 1.1;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 11.8;
Number of respondents: 93.
3. $10,001 to $20,000;
Checked (percentage): 22.6;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 17.2;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 11.8;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 10.8;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 3.2;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 18.3;
Number of respondents: 93.
[End of table]
Table: Q15. How did VA CRNA annual salaries at this facility generally
compare with local market area CRNA salaries from October 1, 2005-
September 30, 2006 for new graduate CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 3.2;
Number of respondents: 93.
2. VA CRNA salaries were lower;
Checked (percentage): 68.8;
Number of respondents: 93.
3. VA CRNA salaries were commensurate;
Checked (percentage): 6.5;
Number of respondents: 93.
4. Don't know; Checked (percentage): 17.2;
Number of respondents: 93.
[End of table]
Table: Q16. How did VA CRNA annual salaries at this facility generally
compare with local market area CRNA salaries from October 1, 2005-
September 30, 2006 for experienced CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 4.3;
Number of respondents: 93.
2. VA CRNA salaries were lower;
Checked (percentage): 78.5;
Number of respondents: 93.
3. VA CRNA salaries were commensurate;
Checked (percentage): 9.7;
Number of respondents: 93.
4. Don't know;
Checked (percentage): 7.5;
Number of respondents: 93.
[End of table]
Table: Q17. If this facility's 2006 VA CRNA salaries were higher than
local market area salaries, how much lower were the salaries for new
graduate CRNAs?
1. $5,000 or less;
Checked (percentage): 1.1;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 3.2;
Number of respondents: 93.
3. $10,001 to $20,000;
Checked (percentage): 0;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 0;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 0;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 0;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 72.0;
Number of respondents: 93.
[End of table]
Table: Q18. If this facility's 2006 VA CRNA salaries were higher than
local market area salaries, how much lower were the salaries for
experienced CRNAs?
1. $5,000 or less;
Checked (percentage): 0;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 3.2;
Number of respondents: 93.
3. $10,001 to $20,000;
Checked (percentage): 1.1;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 0;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 0;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 0;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 71.0;
Number of respondents: 93.
[End of table]
Table: Q19. If this facility's 2006 VA CRNA salaries were lower than
local market area salaries, how much lower were the salaries for new
graduate CRNAs?
1. $5,000 or less;
Checked (percentage): 2.2;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 6.5;
Number of respondents: 93.
3. $10,001 to $20,000;
Checked (percentage): 20.4;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 21.5;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 11.8;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 2.2;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 4.3;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 22.6;
Number of respondents: 93.
[End of table]
Table: Q20. If this facility's 2006 VA CRNA salaries were lower than
local market area salaries, how much lower were the salaries for
experienced CRNAs?
1. $5,000 or less;
Checked (percentage): 1.1;
Number of respondents: 93.
2. $5,001 to $10,000;
Checked (percentage): 10.8; Number of respondents: 93.
3. $10,001 to $20,000; Checked (percentage): 23.7;
Number of respondents: 93.
4. $20,001 to $30,000;
Checked (percentage): 18.3;
Number of respondents: 93.
5. $30,001 to $40,000;
Checked (percentage): 10.8;
Number of respondents: 93.
6. $40,001 to $50,000;
Checked (percentage): 7.5;
Number of respondents: 93.
7. Over $50,000;
Checked (percentage): 4.3;
Number of respondents: 93.
8. Not applicable;
Checked (percentage): 17.2;
Number of respondents: 93.
[End of table]
Table: Q21. What were the reasons this facility used contract CRNAs
from October 1, 2004-September 30, 2005?
1. Retirement of VA CRNAs;
Checked (percentage): 13.6;
Number of respondents: 44.
2. Short-term coverage for an absence of a VA CRNA;
Checked (percentage): 31.8;
Number of respondents: 44.
3. Hiring freeze;
Checked (percentage): 4.6;
Number of respondents: 44.
4. Shortage of CRNAs in the local market area;
Checked (percentage): 40.9;
Number of respondents: 44.
5. Higher than anticipated vacancy rate;
Checked (percentage): 9.1;
Number of respondents: 44.
6. Higher than anticipated surgical volume;
Checked (percentage): 13.6;
Number of respondents: 44.
7. Difficulty in recruiting VA CRNAs;
Checked (percentage): 52.3;
Number of respondents: 44.
8. Difficulty in retaining VA CRNAs;
Checked (percentage): 27.3;
Number of respondents: 44.
9. Coverage for VA CRNAs called to active duty;
Checked (percentage): 15.9;
Number of respondents: 44.
[End of table]
Table: Q22. What were the reasons this facility used contract CRNAs
from October 1, 2005-September 30, 2006?
1. Retirement of VA CRNAs;
Checked (percentage): 13.6;
Number of respondents: 44.
2. Short-term coverage for an absence of a VA CRNA;
Checked (percentage): 27.3;
Number of respondents: 44.
3. Hiring freeze;
Checked (percentage): 4.6;
Number of respondents: 44.
4. Shortage of CRNAs in the local market area;
Checked (percentage): 38.6;
Number of respondents: 44.
5. Higher than anticipated vacancy rate;
Checked (percentage): 11.4;
Number of respondents: 44.
6. Higher than anticipated surgical volume;
Checked (percentage): 11.4;
Number of respondents: 44.
7. Difficulty in recruiting VA CRNAs;
Checked (percentage): 45.5;
Number of respondents: 44.
8. Difficulty in retaining VA CRNAs;
Checked (percentage): 29.6;
Number of respondents: 44.
9. Coverage for VA CRNAs called to active duty;
Checked (percentage): 9.1;
Number of respondents: 44.
[End of table]
[End of section]
Appendix IV Analysis of GAO Survey of VA Medical Facility Human
Resources Officers:
To obtain the views of VA human resources officers on various
recruitment and retention issues, we conducted a Web-based survey of VA
human resources officers, one representing each VA medical facility.
The questionnaire contained questions related to CRNAs recruitment and
retention issues, such as CRNA salary, locality pay surveys, and
bonuses given for recruitment and retention. Not all column totals will
add to 100 percent due to rounding, multiple answers to questions that
ask respondents to check all that apply, and no response by VA medical
facility human resources officers to some questions.
Table: Q1. Over the last 2 years what criteria were used to determine
whether a VA CRNA was paid a recruitment incentive?
1. Local market area starting salaries are higher for new graduate
CRNAs;
2005 Checked (percentage): 27.4;
2005 Number of respondents: 73;
2006 Checked (percentage): 28.8; 2006 Number of respondents: 73.
2. Local market area starting salaries are higher for experienced
CRNAs;
2005 Checked (percentage): 31.5;
2005 Number of respondents: 73;
2006 Checked (percentage): 35.6;
2006 Number of respondents: 73.
3. Salary at this facility does not match a CRNA's previous employer's
salary;
2005 Checked (percentage): 28.7;
2005 Number of respondents: 73;
2006 Checked (percentage): 36.9;
2006 Number of respondents: 73.
4. Local market area tuition reimbursement is higher;
2005 Checked (percentage): 4.1;
2005 Number of respondents: 73;
2006 Checked (percentage): 6.9;
2006 Number of respondents: 73.
5. Local market area benefit package is more competitive;
2005 Checked (percentage): 6.9;
2005 Number of respondents: 73;
2006 Checked (percentage): 9.6;
2006 Number of respondents: 73.
6. Difficulties in commuting to this facility;
2005 Checked (percentage): 4.1;
2005 Number of respondents: 73;
2006 Checked (percentage): 4.1;
2006 Number of respondents: 73.
7. Did not offer any recruitment incentives;
2005 Checked (percentage): 27.4;
2005 Number of respondents: 73;
2006 Checked (percentage): 28.8;
2006 Number of respondents: 73.
[End of table]
Table: Q2. Over the last 2 years what criteria were used to determine
whether a VA CRNA was paid a relocation incentive?
1. Local market area starting salaries are higher for new graduate
CRNAs;
2005 Checked (percentage): 6.9;
2005 Number of respondents: 73;
2006 Checked (percentage): 12.3;
2006 Number of respondents: 73.
2. Local market area starting salaries are higher for experienced
CRNAs;
2005 Checked (percentage): 9.6;
2005 Number of respondents: 73;
2006 Checked (percentage): 13.7;
2006 Number of respondents: 73.
3. Salary at this facility does not match a CRNA's previous employer's
salary;
2005 Checked (percentage): 5.5;
2005 Number of respondents: 73;
2006 Checked (percentage): 11.0;
2006 Number of respondents: 73.
4. Local market area tuition reimbursement is higher;
2005 Checked (percentage): 2.7;
2005 Number of respondents: 73;
2006 Checked (percentage): 5.5;
2006 Number of respondents: 73.
5. Local market area benefit package is more competitive;
2005 Checked (percentage): 2.7;
2005 Number of respondents: 73;
2006 Checked (percentage): 4.1;
2006 Number of respondents: 73.
6. Difficulties in commuting to this facility;
2005 Checked (percentage): 2.7;
2005 Number of respondents: 73;
2006 Checked (percentage): 2.7;
2006 Number of respondents: 73.
7. Did not offer any relocation incentives;
2005 Checked (percentage): 60.3;
2005 Number of respondents: 73;
2006 Checked (percentage): 58.9;
2006 Number of respondents: 73.
[End of table]
Table: Q3. Over the last 2 years what criteria were used to determine
whether a VA CRNA was paid a retention incentive?
1. Local market area salaries are higher for experienced CRNAs;
2005 Checked (percentage: 27.4;
2005 Number of respondents: 73;
2006 Checked (percentage): 32.9;
2006 Number of respondents: 73.
2. CRNA has an alternative job offer;
2005 Checked (percentage: 20.6; 2005 Number of respondents: 73;
2006 Checked (percentage): 27.4;
2006 Number of respondents: 73.
3. Delay retirement of CRNAs;
2005 Checked (percentage: 8.2;
2005 Number of respondents: 73;
2006 Checked (percentage): 16.4;
2006 Number of respondents: 73.
4. Prevent or delay CRNAs leaving this VA facility;
2005 Checked (percentage: 32.9;
2005 Number of respondents: 73;
2006 Checked (percentage): 37.0;
2006 Number of respondents: 73.
5. Local market area benefit package is more competitive;
2005 Checked (percentage: 4.1;
2005 Number of respondents: 73;
2006 Checked (percentage): 8.2;
2006 Number of respondents: 73.
6. Difficulties in commuting to this facility;
2005 Checked (percentage: 1.4;
2005 Number of respondents: 73;
2006 Checked (percentage): 1.4;
2006 Number of respondents: 73.
7. Did not offer any retention incentives;
2005 Checked (percentage: 41.1;
2005 Number of respondents: 73;
2006 Checked (percentage): 31.5;
2006 Number of respondents: 73.
[End of table]
Table: Q4. What types of CRNA salary information were included in the
2005 locality pay survey?
1. Did not conduct a locality pay survey;
Checked (percentage): 7.3;
Number of respondents: 82.
2. Salaries of CRNAs employed by universities, colleges and hospitals;
Checked (percentage): 68.3;
Number of respondents: 82.
3. Salaries of CRNAs employed by free standing ambulatory surgical
centers;
Checked (percentage): 3.7;
Number of respondents: 82.
4. Salaries of CRNAs employed by physicians groups, offices and
clinics;
Checked (percentage): 9.7;
Number of respondents: 82.
5. Salaries of CRNAs employed by CRNA only groups;
Checked (percentage): 0;
Number of respondents: 82.
6. Salaries of CRNAs employed by the government or military;
Checked (percentage): 11.0;
Number of respondents: 82.
7. Salaries of CRNAs working through an agency;
Checked (percentage): 1.2;
Number of respondents: 82.
8. Salaries of CRNAs working as independent contractors;
Checked (percentage): 2.4;
Number of respondents: 82.
9. Don't know;
Checked (percentage): 3.7;
Number of respondents: 82.
[End of table]
Table: Q5. In the 2005 locality pay survey, did a sufficient number of
respondents provide survey data?
1. Yes;
Checked (percentage): 64.6;
Number of respondents: 82.
2. No;
Checked (percentage): 17.1;
Number of respondents: 82.
[End of table]
If yes, what actions did Human Resources take to address the
insufficient number of survey respondents?
1. Expanded the geographic boundaries of the local labor market area;
Checked (percentage): 11.4;
Number of respondents: 35.
2. Contracted for a new survey;
Checked (percentage): 2.9;
Number of respondents: 35.
3. Expanded the types of establishment surveyed;
Checked (percentage): 5.7;
Number of respondents: 35.
4. Conducted own survey;
Checked (percentage): 11.4;
Number of respondents: 35.
5. Raised wages to match the annual cost of living adjustment (COLA);
Checked (percentage): 22.9;
Number of respondents: 35.
6. No action was taken;
Checked (percentage): 8.6;
Number of respondents: 35.
[End of table]
Table: Q6. Overall were you satisfied with the CRNA salary information
you received in the 2005 locality pay survey?
1. Yes;
Checked (percentage): 59.8;
Number of respondents: 82.
2. No;
Checked (percentage): 17.1;
Number of respondents: 82.
[End of table]
Table: Q7. How did 2005 VA CRNA annual salaries at this facility
generally compare with local market area annual salaries for new
graduate CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 2.7;
Number of respondents: 110.
2. VA CRNA salaries were lower;
Checked (percentage): 43.6;
Number of respondents: 110.
3. VA CRNA salaries were commensurate;
Checked (percentage): 8.2;
Number of respondents: 110.
4. Don't know;
Checked (percentage): 39.1;
Number of respondents: 110.
[End of table]
Table: Q8. How did 2005 VA CRNA annual salaries at this facility
generally compare with local market area annual salaries for
experienced CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 1.8;
Number of respondents: 110.
2. VA CRNA salaries were lower;
Checked (percentage): 48.2;
Number of respondents: 110.
3. VA CRNA salaries were commensurate;
Checked (percentage): 15.5;
Number of respondents: 110.
4. Don't know;
Checked (percentage): 27.3;
Number of respondents: 110.
[End of table]
Table: Q9. If this facility's 2005 VA CRNA annual salaries were higher
than local market area salaries, how much higher were the VA CRNA
salaries for new graduate CRNAs?
$5,000 or less;
Checked (percentage): 1.8;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 0.9;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 0.9;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 0.9;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 0.9;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 2.7;
Number of respondents: 110.
Not applicable;
Checked (percentage): 74.5;
Number of respondents: 110.
[End of table]
Table: Q10. If this facility's 2005 VA CRNA annual salaries were higher
than local market area salaries, how much higher were the VA CRNA
salaries for experienced CRNAs?
$5,000 or less;
Checked (percentage): 2.7;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 0;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 0;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 0;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 1.8;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 2.7;
Number of respondents: 110.
Not applicable;
Checked (percentage): 74.5;
Number of respondents: 110.
[End of table]
Table: Q11. If this facility's 2005 VA CRNA annual salaries were lower
than local market area salaries, how much lower were the VA CRNA
salaries for new graduate CRNAs?
$5,000 or less;
Checked (percentage): 6.4;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 13.6;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 12.7;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 4.6;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 4.6;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Not applicable;
Checked (percentage): 47.3;
Number of respondents: 110.
[End of table]
Table: Q12. If this facility's 2005 VA CRNA annual salaries were lower
than local market area salaries, how much lower were the VA CRNA
salaries for experienced CRNAs?
$5,000 or less;
Checked (percentage): 7.3;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 15.5;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 14.6;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 6.4;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 5.5;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 0.9;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Not applicable;
Checked (percentage): 39.1;
Number of respondents: 110.
[End of table]
Table: Q13. What types of CRNA salary information were included in the
2006 locality pay survey?
1. Did not conduct a locality pay survey;
Checked (percentage): 6.1;
Number of respondents: 82.
2. Salaries of CRNAs employed by universities, colleges and hospitals;
Checked (percentage): 67.1;
Number of respondents: 82.
3. Salaries of CRNAs employed by free standing ambulatory surgical
centers;
Checked (percentage): 4.9;
Number of respondents: 82.
4. Salaries of CRNAs employed by physicians groups, offices and
clinics;
Checked (percentage): 7.3;
Number of respondents: 82.
5. Salaries of CRNAs employed by CRNA only groups;
Checked (percentage): 0;
Number of respondents: 82.
6. Salaries of CRNAs employed by the government or military;
Checked (percentage): 11.0;
Number of respondents: 82.
7. Salaries of CRNAs working through an agency;
Checked (percentage): 0;
Number of respondents: 82.
8. Salaries of CRNAs working as independent contractors;
Checked (percentage): 0;
Number of respondents: 82.
9. Don't know;
Checked (percentage): 3.7;
Number of respondents: 82.
[End of table]
Table: Q14. In the 2006 locality pay survey, did a sufficient number of
respondents provide survey data?
1. Yes;
Checked (percentage): 64.6;
Number of respondents: 82.
2. No;
Checked (percentage): 15.9;
Number of respondents: 82.
[End of table]
Table: Q15. Overall were you satisfied with the CRNA salary information
you received in the 2006 locality pay survey?
1. Yes;
Checked (percentage): 62.2;
Number of respondents: 82.
2. No;
Checked (percentage): 13.4;
Number of respondents: 82.
[End of table]
Table: Q16. How did 2006 VA CRNA annual salaries at this facility
generally compare with local market area annual salaries for new
graduate CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 2.7;
Number of respondents: 110.
2. VA CRNA salaries were lower;
Checked (percentage): 46.4;
Number of respondents: 110.
3. VA CRNA salaries were commensurate;
Checked (percentage): 5.5;
Number of respondents: 110.
4. Don't know;
Checked (percentage): 38.2;
Number of respondents: 110.
[End of table]
Table: Q17. How did 2006 VA CRNA annual salaries at this facility
generally compare with local market area annual salaries for
experienced CRNAs?
1. VA CRNA salaries were higher;
Checked (percentage): 2.7;
Number of respondents: 110.
2. VA CRNA salaries were lower;
Checked (percentage): 45.5;
Number of respondents: 110.
3. VA CRNA salaries were commensurate;
Checked (percentage): 19.1;
Number of respondents: 110.
4. Don't know;
Checked (percentage): 25.4;
Number of respondents: 110.
[End of table]
Table: Q18. If this facility's 2006 VA CRNA annual salaries were higher
than local market area salaries, how much higher were the VA CRNA
salaries for new graduate CRNAs?
$5,000 or less;
Checked (percentage): 1.8;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 1.8;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 0.9;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 0;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 0.9;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 1.8;
Number of respondents: 110.
Not applicable;
Checked (percentage): 73.6;
Number of respondents: 110.
[End of table]
Table: Q19. If this facility's 2006 VA CRNA annual salaries were higher
than local market area salaries, how much higher were the VA CRNA
salaries for experienced CRNAs?
$5,000 or less;
Checked (percentage): 1.8;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 2.7;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 0;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 0;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 0.9;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 1.8;
Number of respondents: 110.
Not applicable;
Checked (percentage): 73.6;
Number of respondents: 110.
[End of table]
Table: Q20. If this facility's 2006 VA CRNA annual salaries were lower
than local market area salaries, how much lower were the VA CRNA
salaries for new graduate CRNAs?
$5,000 or less;
Checked (percentage): 5.5;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 13.6;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 11.8;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 5.5;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 4.5;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 0;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 1.8;
Number of respondents: 110.
Not applicable;
Checked (percentage): 46.4;
Number of respondents: 110.
[End of table]
Table: Q21. If this facility's 2006 VA CRNA annual salaries were lower
than local market area salaries, how much lower were the VA CRNA
salaries for experienced CRNAs?
$5,000 or less;
Checked (percentage): 3.6;
Number of respondents: 110.
$5,001 to $10,000;
Checked (percentage): 19.1;
Number of respondents: 110.
$10,001 to $20,000;
Checked (percentage): 12.7;
Number of respondents: 110.
$20,001 to $30,000;
Checked (percentage): 4.5;
Number of respondents: 110.
$30,001 to $40,000;
Checked (percentage): 3.6;
Number of respondents: 110.
$40,001 to $50,000;
Checked (percentage): 2.7;
Number of respondents: 110.
Over $50,000;
Checked (percentage): 0.9;
Number of respondents: 110.
Not applicable;
Checked (percentage): 41.8;
Number of respondents: 110.
[End of table]
Table: Q22. Has this facility ever requested approval to rehire VA
CRNAs retired from federal service without affecting their retirement
pay under the provisions of the Health Care Programs Enhancement Act of
2001 (P.L. 107-135)?
1. Yes;
Checked (percentage): 7.3;
Number of respondents: 110.
2. No;
Checked (percentage): 92.7;
Number of respondents: 110.
[End of table]
[End of section]
Appendix V: Description of Education and Training Requirements for
Anesthesia Practitioners:
Table 4:
Description: Description of practice;
Anesthesiologists: Anesthesiologists are physicians who administer
anesthesia services to relieve pain and medically manage a patient's
vital life functions throughout any surgical, obstetrical, or other
medical procedure;
Certified Registered Nurse Anesthetists (CRNA): CRNAs are registered
nurses that work with anesthesiologists, surgeons, or dentists. In some
states, CRNAs do not have to have direct supervision;
Anesthesiologist Assistants (AA): AAs are allied health professionals
that work under the supervision of a licensed anesthesiologist to
deliver anesthesia services.
Description: Education and training;
Anesthesiologists: Must have a bachelor's degree to enter medical
school. During medical school, students rotate through internal
medicine, family practice, obstetrics, gynecology, pediatrics,
psychiatry and surgery. Following medical school, they have a 4-year
anesthesiology residency program, which includes a year of clinical
medicine, two years of anesthesiology, and one year of concentrated
study and experience with anesthetic complications. Following
residency, they may pursue additional training in specific areas of
anesthesiology;
Certified Registered Nurse Anesthetists (CRNA): Registered nurses with
a bachelor's degree, current licensure, and at least 1 year's
experience in an acute care setting. Trained in anesthesia techniques
and procedures for all types of surgery and obstetrics. Must have
performed 550 anesthesia cases to be eligible for certification;
Anesthesiologist Assistants (AA): Premedical undergraduate courses.
Completion of an accredited anesthesiologist assistant program. Trained
in patient monitoring, anesthesia delivery systems, patient assessment,
and life support systems. Typically, have a minimum of 2,000 clinical
hours in direct patient anesthesia-related care.
Description: Training programs;
Anesthesiologists: 129 medical schools with anesthesia programs in the
United States;
Certified Registered Nurse Anesthetists (CRNA): 106 accredited graduate-
level programs in the United States;
Anesthesiologist Assistants (AA): 4 programs within a school of
medicine in the United States.
Description: Length of training program;
Anesthesiologists: 4 years of undergraduate school;
4 years of medical school; and 4 years of residency;
Certified Registered Nurse Anesthetists (CRNA): 24-36 months in a CRNA
training program;
Anesthesiologist Assistants (AA): 24-28 months in an AA training
program.
Description: Degree conferred;
Anesthesiologists: Doctor of Medicine (MD) or a Doctor of Osteopathic
Medicine (DO);
Certified Registered Nurse Anesthetists (CRNA): Masters or doctoral
degree from an accredited CRNA education program;
Anesthesiologist Assistants (AA): Master of Science degree.
Description: National Certification Examination;
Anesthesiologists: Must obtain a state license to practice in a state.
Anesthesiologists may obtain board certification by passing an
examination. They must periodically meet continuing medical education
credit requirements that vary by state;
Certified Registered Nurse Anesthetists (CRNA): CRNAs must hold a
current registered nurse license and pass a national certification exam
to obtain a national certification. They recertify every 2 years by
obtaining 40 continuing medical education credits and must attest to
being involved in 850 hours of practice involving anesthesia;
Anesthesiologist Assistants (AA): At a minimum, AAs must obtain a
national certification and must recertify every 2 years by submitting
40 continuing medical education credits. Every sixth year, AAs must
pass a written board examination.
Sources: The American Society of Anesthesiologists, American
Association of Nurse Anesthetists, and American Academy of
Anesthesiologist Assistants.
[End of table]
[End of section]
Appendix VI: Comments from the Department Of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
November 14, 2007:
Ms. Laurie E. Ekstrand:
Director, Health Care:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Ekstrand:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA HEALTH CARE: Many
Medical Facilities Have Challenges in Recruiting and Retaining Nurse
Anesthetists (GAO-08-56) and generally agrees with GAO's conclusions
and concurs with GAO's recommendations.
While the Department agrees with GAO's conclusion, we have reservations
about GAO's reliance on self-reporting surveys of certified registered
nurse anesthetists (CRNA) and Chiefs of Anesthesiology in developing
its report. Using such an approach may increase the natural tendency of
those being surveyed to inflate their perceptions of recruitment and
retention difficulties with hopes that findings might encourage
additional resource support for their professions.
GAO states that its surveys indicate that 26 percent of VA's CRNAs
reported that they would retire or leave VA employment in the next 5
years. Taken literally, this would indicate the CRNA turnover during
that time would average 5.2 percent annually. In fact, this represents
a very low potential turnover rate. To put these figures in
perspective, over the past 5 years, CRNA turnover in VA has ranged from
a low of 10.02 percent in fiscal year (FY) 2004 to a high of 15.6
percent in FY 2005. In FY 2007, the rate was 13.22 percent. While a
turnover rate over 10 percent is considered significant, these turnover
rates are not alarming when compared with some other VA health care
occupations. For example, according to J. Walter Thompson (JWT)
Employment Communications, a major national employment advertising,
communications and consulting firm, yearly turnover rates in private
sector health care occupations average more than 20 percent.
The report also highlights the fact that more than 50 percent of VA
CRNAs are over 51 years of age, implying that VA is at increased risk
for losing a significant number of CRNAs to retirement. The fact that
an employee is 51 years old does not necessarily mean that the employee
is retirement eligible or inclined to retire when eligible. VA's
official personnel data estimate that only about 14 percent of VA CRNAs
were eligible to retire in FY 2007. This percentage is projected to
gradually increase to 24 percent retirement eligibility in FY 2013.
Based on past retirement rates, the projected percentage of CRNAs who
will retire ranges from 2 percent in FY 2008 to a high of 4 percent in
FY 2013.
In summary, despite concerns about the study methodology, the
Department acknowledges GAO's conclusions about the recognized
obstacles faced in recruiting and retaining qualified CRNAs. Statutory
salary caps for CRNAs have indeed presented fundamental obstacles in
our recruitment and retention efforts, as GAO reports, but because of
the concerted efforts of VA managers at all levels of the organization
to give credence to VA's reputation as an "employer of choice," we have
been fairly successful thus far to balance workload and staffing
demands.
The enclosures specifically addresses GAO's recommendation and provides
technical comments to the draft report. VA appreciates the opportunity
to comment on your draft report.
Sincerely yours,
Signed by:
Gordon H. Mansfield:
Acting:
Enclosures:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report VA Health Care: Many Medical
Facilities Have Challenges in Recruiting and Retaining Nurse
Anesthetists (GAO-08-56):
* GAO recommends that VA expedite development and implementation of the
training course on VA's LPS policy for VA medical facility officials
responsible for compliance with the policy.
Concur – The Department of Veterans Affairs (VA) concur with GAO's
recommendation that VA expedite development and implementation of a
training course on VA's locality payment system (LPS) policy.
A draft action plan is provided below. While many of the specific tasks
and deliverables associated with the course development remain to be
identified, we anticipate delivery of on-line curriculum by the end of
fiscal 2008.
Nurse Locality Pay System:
Draft e-Learning Action Plan:
Task: Identify learning objectives: Defining the local labor market
area;
Identifying third party salary surveys;
Planning and conducting VA salary surveys;
Constructing salary schedules.
Anticipated Completion Date: TBD.
Task: Develop course content to include tasks and activities;
Anticipated Completion Date: TBD.
Task: Create links to VA policy and legal statutes;
Anticipated Completion Date: TBD.
Task: Activate training module for nationwide use;
Anticipated Completion Date: 9/30/2008.
Technical Comments:
GAO states that VA has not provided training since VA policy was
revised in 2001. It should be clarified VAs last major LPS policy was
implemented on October 25, 2002. Nationwide training on newly added
provisions was conducted via a 2-hour conference call on November 7,
2002, and was followed with the provision of job tools and aids such as
worksheets.
[End of section]
Appendix VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
Laurie E. Ekstrand at (202) 512-7114 or ekstrandl@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Marcia A. Mann, Assistant
Director; N. Rotimi Adebonojo; Michelle M. Alletto; Mary Ann Curran;
Linda Diggs; Martha A. Fisher; Krister Friday; Molly Ryan; James R.
Walker; and Suzanne Worth made key contributions to this report.
[End of section]
Footnotes:
[1] Anesthesia care involves the administration of anesthesia to
patients undergoing surgical or other invasive procedures.
[2] For this report, we used the salaries reported by AANA CRNA members
in the state where a VA medical facility is located as a proxy for the
salary of CRNAs in the local market area. We used CRNA salaries
excluding benefits because although we could obtain quantifiable
benefits data from VA, we could not obtain the same data from non-VA
sources. We also learned from a VA official that salaries, rather than
benefits, were more important to new CRNA graduates.
[3] The Office of Personnel Management regulations use the word
incentive in lieu of the word bonus. However, for the purposes of this
report, we continue to use the term bonus.
[4] Eight of 15 VA medical facilities that had a 40 percent or more
vacancy rate had three or fewer VA CRNA positions. Therefore, one
vacant VA CRNA position represents a large proportion of their total VA
CRNA workforce.
[5] Fiscal year 2005 is the most current VA vacancy data available.
[6] According to VA's 2005 vacancy data, vacancy rates varied
significantly across VA's medical facilities. Many factors contribute
to the difficulty in recruiting VA CRNAs, including difficulty finding
suitable CRNA candidates in the local market area and difficulties or
delays in the hiring process.
[7] Contract CRNAs work for companies that VA medical facilities
contract with to supplement their VA CRNA workforce.
[8] Not all VA chief anesthesiologists who reported using contract
CRNAs in our survey provided data on the number of full-time contract
CRNAs used, the number of hours contracted by their facilities, and the
total contract costs. These numbers represent data for VA medical
facilities that reported both the number of hours and the cost for
contract CRNAs on our survey of VA chief anesthesiologists. These
chiefs reported contracting for CRNAs for a total of 64,938 hours at a
cost of $6,043,826 in fiscal year 2005 and 61,989 hours at a cost of
$5,577,092 in fiscal year 2006.
[9] The VA CRNA hourly rates exclude any recruitment or retention
bonuses. We assumed that full-time VA CRNAs work 40 hours per week or
2,080 hours a year. We also calculated benefits at 30 percent of the VA
CRNA's maximum statutorily prescribed base salary, which was $131,400
in fiscal year 2005 and $133,900 in fiscal year 2006. See 38 U.S.C.
§7451(c)(2)(2000). Because VA CRNA salaries differ across locations
with some locations paying higher salaries, this comparison of VA CRNA
salaries with contract CRNA salaries will differ by location.
[10] While CRNA respondents reported their plans for retirement or
departure from VA, some will change their plans. On the basis of our
survey of VA CRNAs, about one-third of those eligible to retire were
unsure of their retirement plans. However, others who indicated that
they plan to stay may change their plans as well and leave VA. Thus,
this measure is an approximation of likely attrition.
[11] Other reasons that were most frequently cited by chief
anesthesiologists were VA's lengthy hiring process and a shortage of
CRNAs in the local market area.
[12] Experienced VA CRNAs have 2 or more years of experience.
[13] The reason contributing to the difficulty in recruiting and
retaining VA CRNAs most frequently cited by the chief anesthesiologists
besides CRNA salary was inadequate retention bonuses, which, according
to VA HR officers, are often paid because VA CRNA salaries are lower
than the local market area CRNA salaries.
[14] In fiscal year 2005, 44 percent (48) of HR officers reported that
their facilities' starting salaries for new graduate VA CRNAs were low
when compared with CRNA salaries in local market areas, and in fiscal
year 2006, 46 percent (51) of HR officers reported this.
[15] In fiscal year 2005, 48 percent (53) of HR officers reported that
salaries for experienced VA CRNAs were low when compared with CRNA
salaries in local market areas, and in fiscal year 2006, 45 percent
(50) of HR officers reported this.
[16] As reported in appendix II, VA CRNAs responding to our survey
indicated that benefits and a broader scope of practice initially
attracted them to work at VA. Survey respondents, however, also
reported that higher salaries for new graduate CRNAs would improve
recruitment.
[17] Only VA CRNAs who are not eligible to retire in the next 5 years
and who expressed a future employment preference were included in this
analysis.
[18] The maximum statutory salary cap is the maximum base salary a VA
CRNA can earn.
[19] We used VA CRNAs' current fiscal year 2007 maximum statutory
salary cap to determine whether this salary cap when increased by
$9,200, as proposed by the legislation, would be competitive with CRNA
salaries in local market areas. We compared VA CRNA's fiscal year 2007
maximum statutory salary cap, which is currently $136,200 and would
increase to $145,400 with the proposed legislation, with AANA's 2007
salary data for each state in which a VA medical facility is located to
determine whether increasing VA's maximum statutory salary cap as VA
proposes would make VA CRNA salaries competitive with local market area
salaries.
[20] 38 U.S.C. §7410(2000) (authority that VA relies on for relocation
bonuses); 38 U.S.C. §7458(2000) (authorizes payments for recruitment
and retention bonuses). See also 5 U.S.C. §5753(2000).
[21] Evidence that these factors were considered must be fully
documented in the request to pay a bonus.
[22] See 38 U.S.C. §§7671-75; §§7681-83(2000).
[23] EISP provides funding to VA employees, not just VA CRNAs, who are
pursuing educational degrees or training.
[24] Title 38 U.S.C. §7451(d)(2000). VA medical facilities may not set
the minimum rate of basic pay for a grade so that it is greater than
the beginning pay rates for comparable positions at health care
establishments in local market areas. 38 U.S.C. §7451(d)(3)(E)(2000).
[25] The LPS is also used for other occupations, such as registered
nurses.
[26] VA medical facilities may still use salary data if there are fewer
than three job matches at a VA CRNA grade level if the facility
believes the salary data collected are representative of the rates paid
in the local market area and further expansion of the surveyed area
will not be useful.
[27] VA stated in its comments on our draft report that a 2-hour
conference call in November 2002 provided nationwide training on the
new provisions in VA's LPS policy. However, none of the VA medical
facility officials we interviewed mentioned this training session.
[28] Some of the chief anesthesiologists surveyed reported that they
did not have VA CRNAs at their facility.
[29] We sent the HR survey to 170 VA medical facilities because
facilities were answering for both VA CRNA and VA registered nurse
workforce issues. We will be issuing a report on VA registered nurse
workforce issues in fiscal year 2008.
[30] AANA provided salary tables for CRNAs employed in a variety of
health care settings that included the mean, median, 25th percentile,
and 90th percentile for each state.
[31] The BLS employment cost index for wages and salaries in 2006 and
2007 was 2.8 and 3.4 percent, respectively. See BLS, "Employment Cost
Index news release text" (Washington, D.C., 2007) [hyperlink,
http://www.bls.gov/news.release/eci.nr0.htm] (accessed Aug. 14, 2007).
[32] The maximum statutory salary is the maximum base salary a CRNA can
earn.
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