VA Health Care
Recruitment and Retention Challenges and Efforts to Make Salaries Competitive for Nurse Anesthetists Gao ID: GAO-08-647T April 9, 2008Certified registered nurse anesthetists (CRNA), registered nurses who have completed a master's degree program in nurse anesthesia, provide the majority of anesthesia care in the Department of Veterans Affairs (VA) medical facilities. There are approximately 500 VA-employed CRNAs (VA CRNA) who provide care to veterans in VA medical facilities. While the demand for CRNAs has increased, many employed by VA are nearing retirement eligibility age. Concerns have been raised about the challenges VA may face in making VA CRNA salaries competitive in order to maintain its VA CRNA workforce, particularly in local markets that can be highly competitive. This testimony is based on GAO work reported in VA Health Care: Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists, (GAO-08-56, Dec. 13, 2007). This testimony (1) identifies workforce challenges that VA medical facilities experience related to VA CRNAs, and (2) identifies a key mechanism that VA medical facilities have to help make VA CRNA salaries competitive and the extent to which VA facilities use this mechanism. For the December 2007 report, GAO analyzed surveys sent to VA chief anesthesiologists, VA human resources officers, and VA CRNAs. GAO also visited eight VA medical facilities and interviewed facility officials about efforts to recruit and retain VA CRNAs.
GAO reported in December 2007 that VA medical facilities had challenges recruiting and retaining VA CRNAs. In GAO's report, most surveyed officials said that they had difficulty recruiting VA CRNAs at their facilities. The challenge of recruiting VA CRNAs affected the ability of VA officials to reduce existing VA CRNA vacancy rates--the number of unfilled VA CRNA positions--at their medical facilities. Vacancy rates varied across VA and, according to GAO's survey, impacted the delivery of services at VA medical facilities. On the basis of its survey results, GAO also found that in addition to their current recruiting challenges, VA medical facilities would 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 GAO's survey that the recruitment and retention challenges were caused primarily by the low level of VA CRNA salaries when compared with CRNA salaries in local market areas. GAO also reported that VA's locality pay system (LPS) is a key mechanism VA medical facilities can use to determine whether to adjust VA CRNA salaries to help the facilities remain competitive with CRNA salaries in local market areas. GAO also reported that the majority of VA medical facilities that employ VA CRNAs used LPS. However, at the eight VA medical facilities it 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. The problems some VA medical facilities had fully following VA's LPS policy, along with the explanations of facility officials, indicated that VA had not provided adequate training on its LPS policy. As a result, VA medical facility officials cannot ensure that VA CRNA salaries have been adjusted as needed to be competitive in local market areas. Training on the LPS is necessary to help ensure that VA medical facilities are competitive as an employer. In December 2007, GAO recommended that VA expedite the development and implementation of a training course for VA medical facility officials responsible for compliance with the policy. VA agreed with GAO's recommendation and in comments on GAO's draft report stated that it had developed a draft action plan for training staff on its LPS policy. VA anticipated that the online training course would be available by the end of fiscal year 2008.
GAO-08-647T, VA Health Care: Recruitment and Retention Challenges and Efforts to Make Salaries Competitive for Nurse Anesthetists
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Testimony:
Before the Committee on Veterans' Affairs, U.S. Senate:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 9:30 a.m. EDT:
Wednesday, April 9, 2008:
VA Health Care:
Recruitment and Retention Challenges and Efforts to Make Salaries
Competitive for Nurse Anesthetists:
Statement of Marjorie Kanof:
Managing Director:
Health Care:
GAO-08-647T:
GAO Highlights:
Highlights of GAO-08-647T, a testimony before the Committee on
Veterans‘ Affairs, U.S. Senate.
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 in the Department of Veterans Affairs
(VA) medical facilities. There are approximately 500 VA-employed CRNAs
(VA CRNA) who provide care to veterans in VA medical facilities. While
the demand for CRNAs has increased, many employed by VA are nearing
retirement eligibility age. Concerns have been raised about the
challenges VA may face in making VA CRNA salaries competitive in order
to maintain its VA CRNA workforce, particularly in local markets that
can be highly competitive.
This testimony is based on GAO work reported in VA Health Care: Many
Medical Facilities Have Challenges in Recruiting and Retaining Nurse
Anesthetists, (GAO-08-56, Dec. 13, 2007). This testimony (1) identifies
workforce challenges that VA medical facilities experience related to
VA CRNAs, and (2) identifies a key mechanism that VA medical facilities
have to help make VA CRNA salaries competitive and the extent to which
VA facilities use this mechanism.
For the December 2007 report, GAO analyzed surveys sent to VA chief
anesthesiologists, VA human resources officers, and VA CRNAs. GAO also
visited eight VA medical facilities and interviewed facility officials
about efforts to recruit and retain VA CRNAs.
What GAO Found:
GAO reported in December 2007 that VA medical facilities had challenges
recruiting and retaining VA CRNAs. In GAO‘s report, most surveyed
officials said that they had difficulty recruiting VA CRNAs at their
facilities. The challenge of recruiting VA CRNAs affected the ability
of VA officials to reduce existing VA CRNA vacancy rates”the number of
unfilled VA CRNA positions”at their medical facilities. Vacancy rates
varied across VA and, according to GAO‘s survey, impacted the delivery
of services at VA medical facilities. On the basis of its survey
results, GAO also found that in addition to their current recruiting
challenges, VA medical facilities would 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 GAO‘s survey that the recruitment and retention
challenges were caused primarily by the low level of VA CRNA salaries
when compared with CRNA salaries in local market areas.
GAO also reported that VA‘s locality pay system (LPS) is a key
mechanism VA medical facilities can use to determine whether to adjust
VA CRNA salaries to help the facilities remain competitive with CRNA
salaries in local market areas. GAO also reported that the majority of
VA medical facilities that employ VA CRNAs used LPS. However, at the
eight VA medical facilities it 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. The problems some VA
medical facilities had fully following VA‘s LPS policy, along with the
explanations of facility officials, indicated that VA had not provided
adequate training on its LPS policy. As a result, VA medical facility
officials cannot ensure that VA CRNA salaries have been adjusted as
needed to be competitive in local market areas. Training on the LPS is
necessary to help ensure that VA medical facilities are competitive as
an employer. In December 2007, GAO recommended that VA expedite the
development and implementation of a training course for VA medical
facility officials responsible for compliance with the policy. VA
agreed with GAO‘s recommendation and in comments on GAO‘s draft report
stated that it had developed a draft action plan for training staff on
its LPS policy. VA anticipated that the online training course would be
available by the end of fiscal year 2008.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-647T]. For more
information, contact Marjorie Kanof, (202) 512-7114 or kanofm@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here today as you discuss personnel issues in the
Department of Veterans Affairs (VA). One such issue VA faces is an
increased demand for the services provided by certified registered
nurse anesthetists (CRNA), who provide the majority of anesthesia care
veterans receive in medical facilities operated by 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. When hiring VA CRNAs, VA
places them in one of five pay grades, based on the CRNA's education
and experience. The demand for these practitioners 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 has continued 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. Given the increased demand for CRNAs and the important role
they play in providing anesthesia services in VA medical facilities,
concerns have been raised about the challenges VA may face in making VA
CRNA salaries competitive in order to maintain its VA CRNA workforce,
particularly in some local markets where the labor market for CRNAs can
be highly competitive.
In December 2007 we issued a report that examined the challenges VA
faces recruiting and retaining VA CRNAs.[Footnote 1] My remarks today
are based on this report. Specifically, I will (1) identify workforce
challenges that VA medical facilities experience related to VA CRNAs,
and (2) identify a key mechanism that VA medical facilities have to
help make VA CRNA salaries competitive for recruitment and retention
purposes and the extent to which VA facilities use this mechanism.
To do the work for our December 2007 report, we analyzed Web-based
surveys we sent to all VA chief anesthesiologists, VA human resources
(HR) officers, and VA CRNAs, with survey response rates of 92, 85, and
76 percent, respectively. 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 at the time of our
review. Additionally, we obtained data on VA CRNAs' salaries for 2005,
2006, and 2007 and compared these to national salary data we obtained
from the American Association of Nurse Anesthetists (AANA), a
professional organization for CRNAs. We visited eight VA medical
facilities[Footnote 2] and interviewed chief anesthesiologists, VA
CRNAs, HR officers, and other facility officials about their efforts to
recruit and retain VA CRNAs. We also interviewed a representative from
Kaiser Permanente, a large health care plan that primarily uses CRNAs
to deliver anesthesia services, to identify what steps this 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 survey and
national salary data we used, we performed a systematic review of the
returned questionnaires and interviewed VA and AANA officials about the
quality checks and edits they performed on their data. We determined
that the data we used were adequate for our purposes. We conducted our
work from June 2006 through October 2007 in accordance with generally
accepted government auditing standards. Those standards require that we
plan and perform the audit to obtain sufficient, appropriate evidence
to provide a reasonable basis for our findings based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings based on our audit objectives.
In summary, in December 2007 we reported that VA medical facilities had
challenges recruiting and retaining VA CRNAs. Seventy-four percent of
the VA chief anesthesiologists who responded to our survey reported
that they had difficulty recruiting VA CRNAs in fiscal years 2005 and
2006. The challenge of recruiting VA CRNAs affected the ability of VA
officials to reduce existing VA CRNA vacancy rates at their medical
facilities. In our survey, 54 percent of the VA chief anesthesiologists
with VA CRNA vacancies reported that they temporarily closed operating
rooms, and 72 percent reported that they delayed elective surgeries as
a result of VA CRNA vacancies in fiscal year 2006. Based on our survey
results, we also found that in addition to their current recruiting
challenges, VA medical facilities would 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 were caused primarily by the low level of VA CRNA salaries
when compared with CRNA salaries in local market areas. In December
2007 we also reported that VA's locality pay system (LPS) is a key
mechanism that VA medical facilities can use to determine whether to
adjust VA CRNA salaries to help the facilities remain competitive with
CRNA salaries in local market areas. We reported that the majority of
VA medical facilities that employ VA CRNAs used LPS. However, at the
eight VA medical facilities we visited, we found that although the
facilities used VA's LPS, five of these facilities did not fully follow
VA's LPS policy correctly in either 2005 or 2006. The problems some VA
medical facilities had fully following VA's LPS policy, along with the
explanations of facility officials, indicated that VA had not provided
adequate training on its LPS policy. As a result, VA medical facility
officials cannot ensure that VA CRNA salaries have been adjusted as
needed to be competitive in local market areas. Training on the LPS is
necessary to help ensure that VA medical facilities are competitive as
an employer.
To improve VA's ability to recruit and retain VA CRNAs, we recommended
that the Secretary of Veterans Affairs direct the Assistant Secretary
for Human Resources and Administration to expedite development and
implementation of a training course on VA's LPS policy for VA medical
facility officials responsible for compliance with the policy. VA
generally agreed with our conclusions and recommendation and stated
that it had developed a draft action plan for training staff on this
policy and anticipated that an online training course would be
available by the end of fiscal year 2008.
VA Medical Facilities Have VA CRNA Recruitment and Retention Challenges
Primarily Because of Noncompetitive Salaries:
We reported in December 2007 that VA medical facilities had challenges
recruiting and retaining VA CRNAs. On the basis of our survey results,
we found that VA medical facilities had challenges in recruiting VA
CRNAs at their facilities and will likely face challenges in 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 were caused
primarily by the low level of VA CRNA salaries when compared with CRNA
salaries in local market areas.
VA Officials Reported Challenges Recruiting CRNAs, and Projected VA
CRNA Attrition Will Likely Create Retention Challenge in the Next 5
Years:
In December 2007 we reported our survey results indicating that VA
medical facilities had a challenge recruiting VA CRNAs.[Footnote 3] Of
all VA medical facility chief anesthesiologists who responded to our
survey, 74 percent reported that they had difficulty recruiting VA
CRNAs in fiscal years 2005 and 2006. The recruiting challenges also
affected 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
took 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 limited the ability of VA officials
to reduce existing vacancy rates at their medical facilities. VA's
fiscal year 2005 vacancy data show that VA had about a 13 percent VA
CRNA vacancy rate systemwide, or 70 unfilled VA CRNA positions at 43
medical facilities. These rates varied 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 suggested that VA CRNA vacancies were 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 facilities, with the number of VA CRNA vacancies ranging from
one to six.
According to our survey, VA CRNA vacancies 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 supplied by outside companies were used to
supplement the VA facilities' VA CRNA workforce. In addition, almost
one-third of the chief anesthesiologists whose vacancies were filled by
VA CRNAs reported that they still had a shortage of CRNAs.
In addition to the challenges of recruiting VA CRNAs, we also reported
that VA medical facilities were likely to face another workforce
challenge in the future. Specifically, we found that in the next 5
years VA medical facilities would 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 projected a VA CRNA attrition rate of 26 percent across VA
in the next 5 years--that is, 26 percent of VA CRNAs either planned to
retire or leave VA's health care system within the next 5
years.[Footnote 4] 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, will likely be 26
percent, this rate will vary by medical facility. In 27 VA medical
facilities, we projected that the attrition rate would likely 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, Recruitment and Retention
Challenges Are Due to Noncompetitive VA CRNA Salaries:
Our surveys of VA medical facility chief anesthesiologists and HR
officers indicated that medical facilities had trouble recruiting and
will have trouble retaining VA CRNAs because salaries for VA CRNAs were
low compared to CRNA salaries in local market areas. Specifically, 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 5] 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
6] 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 7]
Of the chief anesthesiologists we surveyed, 72 percent (67) 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) 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 1 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 1: 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.
Notes: The data are from a GAO survey of 120 VA medical facility chief
anesthesiologists. 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]
In December 2007, we reported that to address recruitment challenges
related to VA CRNA salaries, VA CRNAs and the director of VA's
anesthesia services told us that they were revising VA's CRNA
qualification standards. These standards establish the five pay grades-
-grade I being the lowest--that VA CRNAs are placed into when hired,
based on CRNAs' education and experience. According to the officials,
the change to VA's qualification standards will have the effect of
increasing starting salaries for new graduate VA CRNAs from grade I to
grade II. However, we found that 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 would 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.
We found similar challenges related to the retention of VA CRNAs. At
the time of our review, more than half of all VA CRNAs earned the
maximum statutory salary cap[Footnote 8] for a VA CRNA in 2006, which
was $133,900. However, at 107 of VA's 120 medical facilities that
employ VA CRNAs the 2006 maximum statutory salary cap was at least
$20,000 lower than 2006 CRNA salaries in local market areas. The 2007
maximum statutory salary cap increased to $136,200. According to VA
officials, VA is developing proposed legislation to increase this
maximum statutory salary cap for VA CRNAs by $9,200. Our analysis
comparing AANA 2007 salary data for CRNAs to VA's CRNA 2007 maximum
statutory salary cap indicated that increasing the VA CRNA maximum
statutory salary cap by $9,200 would not, at a majority of VA medical
facilities, make VA CRNA salaries competitive with CRNA salaries in
local market areas. Specifically, using 2007 rates, we found that after
the proposed change, 70 of the 120 VA medical facilities' VA CRNA
salaries would still be at least $20,000 or lower than the local market
area CRNA salaries.
VA Medical Facilities Can Use LPS to Help Make VA CRNA Salaries
Competitive, and While Majority of Facilities Have Used LPS, Some Have
Not Followed VA's LPS Policy:
In December 2007, we reported that VA's LPS system is a key mechanism
that VA medical facilities can use to determine whether to adjust VA
CRNA salaries to help the facilities remain competitive with CRNA
salaries in local market areas. We also reported that the majority of
VA medical facilities that employ VA CRNAs used LPS. However, at the
eight 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.
To Recruit and Retain VA CRNAs, Medical Facilities Can Adjust Salaries
Using VA's LPS:
In December 2007, we reported that VA CRNA pay grades--and thus
salaries--are initially determined by VA's qualification standards for
VA CRNAs. Although VA medical facility directors are required to use
the LPS to determine if VA CRNA salaries should be adjusted, they have
the option of adjusting these salaries to recruit and retain VA CRNAs.
[Footnote 9] When adjusting VA CRNA salaries, VA medical facilities are
required to use a process known as LPS.[Footnote 10] The system is
intended to help VA medical facilities determine whether to adjust VA
CRNA salaries to be regionally competitive. VA's LPS supports this goal
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 has an LPS policy, which 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.
Once the survey is completed, a facility's HR officer reports the
results to the medical facility director and on the basis of the survey
data, recommends whether to adjust VA CRNA salaries. The facility
director makes the final decision on whether to adjust the facility's
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.
The Majority of VA Medical Facilities Used LPS, but Instances of
Incorrect Use Indicated Inadequate Training on LPS Policy:
In December 2007 we reported that according to VA, the majority--86 out
of 120--of the 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 facilities that used VA's LPS, 63 used a third-
party survey to obtain data on local market area salary rates for
CRNAs.
We also reported that, while VA facilities that employed VA CRNAs used
LPS, five of the eight facilities we visited did not use the LPS in
accordance with VA's LPS policy in 2005 or 2006. VA's LPS 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 made
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 from their own
facility-conducted surveys to determine whether VA CRNA salaries should
be adjusted, and officials from these facilities told us they 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
the use of salary data of CRNAs that work for organizations that
contract anesthesia services 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, indicated
that VA had not provided adequate training on its LPS policy. 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, had not conducted nationwide training
on its LPS policy since 1995.[Footnote 11] As a result, VA medical
facility officials had not received LPS training that reflected VA's
current LPS policy and, accordingly could not ensure that VA CRNA
salaries had been adjusted as needed to be competitive.
In our December 2007 report we noted that VA was in the process of
developing a Web-based training course for the LPS that VA medical
facility officials could complete online. We reported that because VA
had not made the training a priority, it had not established a time
frame for finalizing the development and implementation of the training
course. In our December 2007 report we recommended that VA expedite the
development and implementation of the training course for VA medical
facility officials responsible for compliance with the policy. VA
agreed with our recommendation and in comments on our draft report
stated that it had developed a draft action plan for training staff on
its LPS policy. VA anticipated that the online training course would be
available by the end of fiscal year 2008.
Mr. Chairman, this concludes my prepared remarks. I would be happy to
answer any questions you or other members of the committee may have.
Contact and Acknowledgments:
For more information regarding this testimony, please contact Marjorie
Kanof at (202) 512-7114 or kanofm@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. In addition, Marcia Mann, Assistant
Director; N. Rotimi Adebonojo; Mary Ann Curran; Melanie Egorin; and
Krister Friday made key contributions to this testimony.
[End of section]
Footnotes:
[1] GAO, VA Health Care: Many Medical Facilities Have Challenges in
Recruiting and Retaining Nurse Anesthetists, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-56] (Washington, D.C.: Dec.
13, 2007).
[2] The eight VA medical facilities we visited were 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.
[3] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-56].
[4] 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.
[5] 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.
[6] Experienced VA CRNAs have 2 or more years of experience.
[7] 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.
[8] The maximum statutory salary cap is the maximum base salary a VA
CRNA can earn.
[9] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-56]. 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. See 38 U.S.C. §7451(d)(3)(E)(2000).
[10] The LPS is also used for other occupations, such as registered
nurses.
[11] VA stated in its comments on our 2007 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 during our review mentioned this
training session.
[End of section]
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