United States Government Accountability Office Testimony Before the Subcommittee on Health and Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, House of Representatives VETERANS HEALTH For Release on Delivery Expected at 10:30 a.m. ET Wednesday, May 17, 2023 CARE Staffing Challenges and Recommendations for Improvement Statement of Sharon M. Silas, Director, Health Care Page i GAO-23-106836 GAO-23-106836 May 17, 2023 VETERANS HEALTH CARE Staffing Challenges and Recommendations for Improvement Highlights of GAO-23-106836, a testimony before the Subcommittee on Health and Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, House of Representatives Why GAO Did This Study What GAO Found GAO's past work has shown that an The Veterans Health Administration (VHA) operates the nation's largest health agency's workforce plays a central care system, employing more than 371,000 clinical and support staff at 171 role in transforming an agency into a Department of Veterans Affairs (VA) medical centers and more than 1,100 high-performing organization. outpatient facilities. VHA's ability to attract, hire, and retain high-performing staff Recent legislative changes that is critical to its mission to provide quality and timely care for the nation's increased the number of veterans veterans. In recent work, GAO has made several recommendations to VHA to eligible for certain services help address certain staffing challenges, which would help the agency meet significantly affect VHA's staffing veterans' health care needs. VA has agreed with these recommendations and efforts. Growth in veterans' demand reported steps taken to implement them. Recent examples include the following: for community care and mental • Community care staffing needs. VHA developed a staffing tool to help health services has posed its medical facilities determine the number of staff needed for VA's challenges for maintaining an community care program, which allows veterans to obtain care outside of adequate workforce for programs in VA. However, this tool did not require facilities to assess all staffing and these areas. VHA is also in the midst resource needs and most VA facilities in GAO's September 2020 review of modernizing its human resources did not have the staffing tool's recommended number of staff. functions, including key onboarding Additionally, facility staff GAO spoke with reported challenges recruiting tasks that help ensure those working and retaining administrative and clinical staff needed to support the in VA medical facilities are, for community care program. GAO recommended that VA medical facility example, free of problematic leadership assess their facilities' needs and develop a plan to address background issues. any identified risks, including strategies to address recruitment and This statement describes GAO's retention challenges. VA concurred and has taken some steps to update recent work, including the staffing tool to identify staffing and resource needs. recommendations GAO has made to • Integrating mental health care within primary care settings. In GAO's VHA, on (1) staffing needs for its December 2022 review, VA medical facility staff described staffing community care program; (2) challenges that adversely affect efforts to implement programs recruiting and retaining staff for its integrating mental health care within primary care settings. GAO programs that integrate mental recommended that VHA comprehensively evaluate and implement health care within primary care strategies to help mitigate staffing challenges in these programs. VA settings; and (3) monitoring its new concurred and described steps taken to evaluate its current strategies hire onboarding tasks. and establish an action plan to consider further implementation. This statement is based on three • Reliable data to monitor new hire onboarding tasks. VHA lacks the GAO reports issued between reliable data-complete, accurate, and timely-needed to monitor the September 2020 and January 2023 completion of key onboarding tasks for new hires. Specifically, VHA uses (GAO-20-643, GAO-23-105372, and data from the USA Staffing system to monitor these tasks, but GAO's GAO-23-105706). GAO also January 2023 review found that regional and medical facility staff did not reviewed VA documentation on steps consistently enter completion data for the tasks into USA Staffing's taken to address GAO's onboarding module. GAO recommended that VHA (1) require all offices recommendations. involved in onboarding to use USA Staffing to monitor onboarding tasks and completion dates and (2) ensure that regional networks and medical facilities have clear and comprehensive guidance on entering data into USA Staffing. VA concurred with both recommendations and identified actions it had begun, such as developing data-level definitions for View GAO-23-106836. For more information, upcoming USA Staffing user guides. contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov. Implementing our recommendations would better position VHA to meet its mission to provide quality and timely care for the nation's veterans. United States Government Accountability Office Related GAO Reports Chairwomen Miller-Meeks and Kiggans, Ranking Member Brownley, Ranking Member Mrvan, and Members of the Subcommittees: Thank you for the opportunity to discuss our work on the Department of Veterans Affairs' (VA) efforts to staff its medical facilities, including the processes that the Veterans Health Administration (VHA) uses to hire and onboard new staff. VHA operates the nation's largest health care system, serving over 9 million enrolled veterans at 171 VA medical centers and more than 1,100 outpatient facilities. To provide services, VHA employs more than 371,000 clinical and support staff. VHA's ability to attract, hire, and retain high-performing staff is critical to its mission to provide quality and timely care for our nation's veterans. Recent legislative changes increased the number of veterans eligible for certain VHA services, further emphasizing the need for VHA to effectively recruit and retain staff to meet the needs of veterans. 1 For example, according to VA, more than 215,000 veterans enrolled in VHA since the passing of the Honoring our PACT Act (PACT Act) of 2022, which expanded health care for certain veterans, including those exposed to toxic substances. 2 Additionally, with the passage of the VA MISSION Act of 2018, veterans' use of community care continues to grow. 3 According to VA, the number of veterans who received community care increased 64 percent from approximately 1.1 million in 2014 to 1.8 million in 2020. Moreover, the rapid growth in veterans' demand for mental health services has posed challenges for maintaining an adequate mental health workforce that provides timely, high-quality mental health services across VA medical facilities. Specifically, from 2006 through 2020, the number of veterans who received mental health care from VHA grew by 85 1See, for example, the Honoring our PACT Act of 2022, Pub. L. No. 117-168, tit. I, § 103, 136 Stat. 1759, 1762 (2022). 2Pub. L. No. 117-168, tit. I, § 103, 136 Stat. 1759, 1762 (2022). 3In addition to delivering health care services at its own medical facilities, VA allows eligible veterans to receive care from community providers through the Veterans Community Care Program. This program was established by the VA MISSION Act of 2018 and implemented on June 6, 2019. It is the most recent iteration of VA's long-standing practice of allowing veterans to receive care from community providers when they face challenges accessing care at VA medical facilities. See Pub. L. No. 115-182, tit. I, § 101, 132 Stat. 1393, 1395 (2018). Page 1 GAO-23-106836 Related GAO Reports percent-an increase of more than three times the rate for all other VA health care services. In 2015, we added VA health care to our High-Risk List, in which one broad area of concern was unclear resource needs and allocation priorities, including concerns related to staff recruitment and retention. 4 Since then our work has highlighted various VHA staffing efforts, including challenges determining adequate staffing levels for delivering care and recruiting and retaining staff to mitigate staffing shortages. We have also reported on agency efforts to expedite hiring through modifying the onboarding process. On the basis of this work we have made several recommendations to VHA to help ensure it is positioned to effectively meet the growing demand for health care services among veterans. My remarks today summarize key findings from our recent work, including recommendations we have made to VHA and steps the agency has taken to implement them, related to 1. determining and meeting staffing needs for its community care program; 2. recruiting and retaining staff for its programs that integrate mental health care within primary care settings; and 3. monitoring new hire onboarding tasks. This statement is based on our recent work issued between September 2020 and January 2023 reviewing VHA's efforts to staff its medical facilities, including our recommendations to improve these efforts. 5 Detailed information on the objectives, scope, and methodology of this work can be found in each issued report. For this statement, we reviewed VA documentation related to the status of efforts to implement our recommendations since the reports were issued. 4See GAO, High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015). 5See GAO, Veterans Community Care Program: Improvements Needed to Help Ensure Timely Access to Care, GAO-20-643 (Washington, D.C.: Sept. 28, 2020); Veterans Health Care: Staffing Challenges Persist for Fully Integrating Mental Health and Primary Care Services, GAO-23-105372 (Washington, D.C.: Dec. 15, 2022); and VA Health Care: VHA Lacks Reliable Onboarding Data for New Clinical Staff, GAO-23-105706 (Washington, D.C.: Jan. 25, 2023). Page 2 GAO-23-106836 Related GAO Reports We conducted the work on which this statement is based 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 and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. VA and VHA's central human resources (HR) offices are primarily Background responsible for developing HR policy, guidance, and training. Individual regional and medical facility HR offices are responsible for implementing HR policies and managing daily HR operations. For example, VA's Office of Human Resources & Administration develops department-wide HR policies and guidance, provides HR training, and conducts reviews of VA's HR operations. VHA's regional HR staff manage the overall hiring process for VA medical facilities from posting job openings to extending job offers and onboarding staff. Hiring Authorities An important component of the hiring process is the hiring authority used to bring applicants onboard. Among other things, hiring authorities determine the rules (or a subset of rules within a broader set) that agencies must follow throughout the hiring process. For example, VA has used COVID-19 pandemic and other human capital flexibilities to accelerate and expedite hiring in certain circumstances. • We reported in October 2021 that, from March through December 2020, VA used COVID-19 related direct hiring authority to make 4,215 hires and COVID-19 related Schedule A hiring authority to make 913 hires. 6 • We found in February 2023 that VHA used several human capital flexibilities from fiscal years 2016 through 2022 to recruit and retain staff in the U.S. Pacific territories. 7 Specifically, VHA used hiring flexibilities such as exceptions to the competitive hiring process used to fill vacancies and employing other recruitment, relocation, and retention incentives for recruiting and retaining staff. 6See GAO, Federal Hiring: OPM Should Collect and Share COVID-19 Lessons Learned to Inform Hiring During Future Emergencies, GAO-22-104297 (Washington, D.C.: Oct. 25, 2021). 7See GAO, Veterans Health Administration: Hiring Trends in the U.S. Pacific Territories, GAO-23-105953 (Washington, D.C.: Feb. 16, 2023). Page 3 GAO-23-106836 Related GAO Reports New Hire Onboarding When hiring new staff, VHA requires its medical facilities to complete five Process key onboarding tasks that are designed to ensure that those providing care to veterans and working in VA medical facilities are qualified, capable, and free of problematic background issues. These tasks include verifying clinical staffs' qualifications and state licenses to practice (credentialing), conducting physical examinations, and performing drug testing and fingerprint checks. In general, VHA requires these tasks be completed before new clinical staff begin work at VA medical facilities. Multiple offices are responsible for developing policies and procedures related to onboarding and overseeing and completing onboarding tasks for new VHA staff. Regional and medical facility staff are responsible for implementing VHA's onboarding process by completing the five key onboarding tasks for new hires. See figure 1 for the offices involved in completing the key onboarding tasks. Page 4 GAO-23-106836 Related GAO Reports Figure 1: Offices Involved in New Hire Onboarding in the Veterans Health Administration (VHA) a The Defense Counterintelligence and Security Agency, part of the Department of Defense, conducts background investigations for other federal agencies, like VA. Page 5 GAO-23-106836 Related GAO Reports In April 2020, in response to the COVID-19 pandemic, VHA modified its onboarding process in an effort to shorten the time frame for bringing new staff onboard at its facilities. Prior to the COVID-19 pandemic, VHA's requirements were generally to have the five key onboarding tasks completed prior to employees reporting for work. An important change VHA made to its process was to allow some onboarding tasks to be completed after hiring, instead of before. VHA officials stated that they will continue to use expedited onboarding processes after the COVID-19 pandemic ends. HR Modernization Efforts In 2019, VHA began an initiative meant to consolidate its HR services to be more effective and responsive. The first phase of the initiative, completed in fiscal year 2020, consolidated its facility-led HR offices. Each region now has its own HR office. Congress and others have expressed concerns about this consolidation, including that it has made VHA's hiring process worse. For example, there are concerns that, due to VHA's HR modernization efforts, candidates for important clinical positions are being lost after lengthy recruitments due to long delays in extending offers or setting salaries. As part of the second phase of the initiative, VHA headquarters established a team comprising various stakeholders-representing HR, credentialing, and the laboratories where drug testing is performed-to implement a standardized onboarding process. In its most recent update on staffing capacity in June 2022, VHA officials said the project team has defined roles and responsibilities for all staff engaged in onboarding and are currently developing new job aids to implement a standardized onboarding process. VHA also noted that it is taking steps to implement a new enterprise HR process. 8 However, VHA did not provide more specific time frames for these efforts. 9 Community Care Staff VHA, its regional networks, and VA medical facilities all play a role to help Responsibilities ensure VHA is managing referrals and scheduling appointments for community care in a timely manner. For example, facility community care 8See Department of Veterans Affairs, Annual Report on the Steps Taken to Achieve Full Staffing Capacity (Washington, D.C.: June 2022). 9VA health care remains on our High-Risk List for concerns related to unclear resource needs and allocation priorities. In our April 2023 High Risk report, we noted that VHA only included limited steps related to implementing its HR modernization efforts. See GAO, High-Risk Series: Efforts Made to Achieve Progress Need to Be Maintained and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.: Apr. 20, 2023). Page 6 GAO-23-106836 Related GAO Reports staff coordinate and schedule veterans' care with community providers at the local level, such as by reviewing a referral from a VHA provider to determine the veteran's eligibility for community care and taking several actions to schedule the appointment. VHA has established standards that facilities need to meet to ensure the timeliness of scheduling appointments for community care. In January 2023, we reported that most VA medical facilities were unable to meet the standard VHA has established for scheduling community care appointments. 10 In our September 2020 report, we found that facility staff we spoke with Challenges Meeting faced challenges with recruitment and retention, and that most VA Community Care facilities in our review did not have the recommended number of staff and were not hitting timeliness metrics for appointment scheduling. 11 Staffing Needs Understaffed community care offices may affect a facility's ability to handle veteran's community care referrals in a timely manner. Recruitment and retention challenges. VHA officials noted challenges with filling approved positions in VA medical facilities' community care offices, resulting in vacancies at some facilities. Specifically, of the 40 facilities in our review, 16 had administrative staff vacancies, and 19 had clinical staff vacancies, according to VA data. VA medical facility staff mentioned vacancies that involved a range of positions, including a community care office chief, scheduler supervisors, schedulers, social workers, and program support assistants. They said medical facilities can face difficulties recruiting and retaining community care schedulers, due to the perception of low salaries given the complexity and volume of work, the availability of less stressful scheduler positions for facility based care, and little opportunity for advancement. Staffing tool. In our September 2020 report, we also found that a staffing tool VHA developed to help its medical facilities determine the number of staff needed to operate VA's community care program did not require facilities to assess staffing and resource needs for community care 10See GAO, Veterans Health Care: VA Actions Needed to Ensure Timely Scheduling of Specialty Care Appointments, GAO-23-105617 (Washington, D.C.: Jan. 4, 2023). 11See GAO-20-643. Page 7 GAO-23-106836 Related GAO Reports appointment scheduling. 12 If VA medical facilities do not assess the risks to their community care office's ability to schedule veterans' appointments in a timely manner, and take action to address such risks, it increases the likelihood that facilities will lack sufficient staffing and other resources to ensure that veterans receive timely care under VA's community care program. Based on these findings, we recommended that the Under Secretary for Health direct VA medical facility leadership to assess their community care staffing and resource needs, and develop a plan to address any identified risks to their ability to schedule appointments in a timely manner, including strategies to adjust staff levels and address recruitment and retention challenges as needed. 13 VA concurred with our recommendation and has taken some steps but has not yet fully implemented our recommendation. In June 2021, we found that six selected VA medical facilities in our review also noted challenges with facility community care workload and staffing that existed prior to COVID-19 but were highlighted, or in some cases, worsened by the pandemic. 14 Specifically, staff stated that they believed their facility community care offices were understaffed, with some noting specific vacancies in scheduler and clinical positions. As of January 2023, VHA reported that a deficit of community care staff continues to exist for both administrative and clinical positions at VA medical facilities. In January 2023, VHA stated that it last updated the staffing tool in March 2022 to enable each VA medical facility to quantify resource needs and 12The staffing tool includes information entered by VHA staff, such as the average time it takes facility staff to complete referral management tasks, community care referral volume from the previous fiscal year, and expected referral volume growth for the current year. Using these data, the staffing tool outputs a recommended number of administrative and clinical staff each facility's community care office needs to meet timeliness metrics for processing community care referrals and scheduling appointments. 13In our report, we also recommended that Congress consider requiring VA to establish an overall wait-time performance measure for VA's community care program. The report also included two additional recommendations to VHA, including that it align its monitoring metrics with the community care program's appointment scheduling process. See GAO-20-643. 14See GAO, Veterans Community Care Program: VA Took Action on Veterans' Access to Care, but COVID-19 Highlighted Continued Scheduling Challenges, GAO-21-476 (Washington, D.C.: June 28, 2021). Page 8 GAO-23-106836 Related GAO Reports identify the recommended number of administrative and clinical staff based on current workload data, systems, and processes. VHA also stated that VA medical facilities make quarterly updates to the staffing tool, which is then used by the facility community care offices to support position requests and for discussions with leadership regarding community care staffing levels. VHA has also updated its process for scheduling appointments with community care providers with a new procedure for reviewing referrals, called the Referral Coordination Initiative. Under this initiative, VHA transitioned responsibilities for community care appointments from multiple clinical employees to designated referral coordination teams at each VA medical facility. 15 In January 2023, VHA stated that community care staffing needs are expected to evolve further over the next year as processes from the initiative continue to be deployed at VA medical facilities. In our December 2022 report, we found that VA medical facilities' staffing Staffing Challenges challenges adversely affect their efforts to implement programs for Affecting Integration integrating mental health care within primary care settings. 16 These problems date back to at least 2016. As described in our report, facilities of Mental Health Care often reported that staffing-related challenges were one of their most within Primary Care significant challenges to implementing or sustaining program services. Settings Chief mental health officers we spoke with from VHA's regional offices identified more that could be done to assist programs that integrate mental health care within primary care settings. For example, they noted that VHA could use the following strategies: 15According to VHA documentation, the Referral Coordination Initiative aims to improve scheduling timeliness and reduce administrative burden for referring providers by incorporating steps to ensure that referrals are complete and include all pertinent clinical information before referrals are scheduled within VHA or through community providers. 16VHA requires its medical facilities serving at least 5,000 unique veterans annually to integrate mental health services into the primary care services they provide. Specifically, facilities are required to have mental health providers, such as psychologists, psychiatrists, and social workers, available within primary care settings to work collaboratively and share responsibility with primary care providers to (1) assess and treat veterans with mental health symptoms and conditions, such as anxiety or depression; and (2) follow up with those veterans to monitor symptoms and adherence to medications, and provide education and referral services. See Department of Veterans Affairs, Veterans Health Administration, Uniform Mental Health Services in VA Medical Centers and Clinics, VHA Handbook 1160.01 (Washington, D.C.: Sept. 11, 2008, amended Nov. 16, 2015). Page 9 GAO-23-106836 Related GAO Reports • Providing additional guidance. One chief mental health officer said that VHA could provide guidance on strategies to help prevent provider burnout and recruit and retain staff. • Enhancing and increasing funding opportunities. One chief mental health officer said that, since nationwide challenges with HR have interfered with rapid hires, VHA should provide VA medical facilities a longer window to apply for special funding for program positions. Another officer recommended that VHA increase opportunities for funding program positions and fund additional internship and post-doctorate training to ensure a continuous influx of providers. • Engaging facility leadership. Two chief mental health officers said that VHA should hold facility leadership accountable for ensuring adequate program staffing levels. Another chief mental health officer said that VHA could communicate directly with facility leadership and mental health leaders to emphasize the importance of adequate program staffing levels. • Supporting, reinforcing, or revising recommended program clinical staffing levels. Four chief mental health officers said that VHA could do more to support, reinforce, or revise the recommended clinical staffing level it uses to help VA medical facilities determine the appropriate number of program providers each facility should have. For example, two chief mental health officers suggested that VHA make the program's staffing recommendation a requirement for facilities. In our December 2022 report, we recommended that VHA ensure that its Office of Mental Health and Suicide Prevention comprehensively evaluate and implement strategies to help mitigate staffing challenges that affect VHA facilities' abilities to integrate mental health care within primary care settings. 17 VA concurred with our recommendation, stating that mitigating staffing challenges is a top VHA leadership priority. VA has taken some steps but has not yet fully implemented our recommendation. In May 2023, VA stated that the Office of Mental Health and Suicide Prevention evaluated its current strategies to help mitigate staffing challenges that affect VHA facilities' abilities to integrate mental health 17Inour report, we also recommended that VHA ensure that the Office of Mental Health and Suicide Prevention monitors regional networks' development and implementation of corrective action plans for any VA medical facilities that do not fully adhere to VHA's program requirements for integrating mental health care within primary care settings. See GAO-23-105372. Page 10 GAO-23-106836 Related GAO Reports care within primary care settings and established an action plan to consider further implementation of those strategies. In its plan, VHA assessed ten factors based on a review of the Office of Mental Health and Suicide Prevention's current strategies, the strategies documented in our December 2022 report, and other sources. VHA then assessed those factors to determine whether further action should be taken. Of the ten factors in its plan, VHA stated that it had completed an assessment of eight factors and identified a number of strategies with further actions to implement. VHA noted that it is making progress on meeting the plan's objectives and anticipates completing remaining actions outlined in its plan by December 2024. One of VHA's goals for its HR modernization efforts is to establish a Challenges with target benchmark for how long it should take to complete onboarding Reliable Data Needed tasks, such as drug testing and background checks for new hires. These tasks are designed to ensure that those providing care to veterans and to Monitor New Hire working in VA medical facilities are qualified, capable, and free of Onboarding Process problematic background issues. According to VHA officials, the USA Staffing onboarding module is to be used for all onboarding of staff. 18 However, in our January 2023 report, we found that VHA lacks the reliable data-complete, accurate, and timely-it needs to monitor the completion of key onboarding tasks that were expedited or deferred during the COVID-19 pandemic. 19 We found, for example, that regional and medical facility staff did not consistently enter completion data for the key onboarding tasks into USA Staffing's onboarding module. When they did enter the information, VHA officials told us it could be incorrect or late. We found two factors contributed to the incomplete and inconsistent onboarding data in USA Staffing-lack of a comprehensive policy requiring the use of USA Staffing's onboarding module and guidance to help staff enter data in a consistent manner. We made two recommendations to address these factors. 18While multiple data systems are involved in onboarding tasks, USA Staffing is the only system that collects data on the completion of all key onboarding tasks that could have been expedited or deferred during the COVID-19 pandemic. USA Staffing is a government-wide staffing tool developed by the Office of Personnel Management, and is used to recruit, evaluate, assess, certify, select, and onboard staff. According to the Office of Personnel Management website, one of the benefits of the tool is to streamline the onboarding process. According to officials, some important onboarding data (in particular, whether an employee had a favorable outcome for the onboarding task) is not available in USA Staffing. 19See GAO-23-105706. Page 11 GAO-23-106836 Related GAO Reports Lack of a comprehensive policy requiring the use of USA Staffing for onboarding clinical staff. In December 2018, VA instructed HR staff to use USA Staffing to load and manage some onboarding tasks, such as fingerprinting. However, VA did not specify how, if at all, USA Staffing is to be used to track the other key onboarding tasks-credentialing, drug testing, and physical examinations. VA's instructions also did not address all of the staff that perform data entry into USA Staffing, such as VA medical facility staff. Without a clear, comprehensive policy requiring the use of USA Staffing, the use of this system will likely be inconsistent, and as a result, VHA will continue to lack the complete data it needs to oversee the completion of onboarding tasks. To address this issue, we recommended that VHA require all offices involved in onboarding to use USA Staffing to monitor onboarding tasks and completion dates. VA concurred with our recommendation and identified actions VHA is taking, such as developing an implementation plan that includes drafting and issuing an Under Secretary for Health memorandum mandating relevant staff use USA Staffing. VHA estimated that it will complete these efforts in August 2023. Lack of comprehensive guidance for using USA Staffing, including definitions for data entry fields. Although VHA has issued various guidance and instructions on how to enter information into USA Staffing, we found in our January 2023 report that regional HR directors cited varying amounts of guidance for entering information into USA Staffing and some regional HR directors were dissatisfied with the guidance. Ensuring that USA Staffing has complete, accurate, and timely data is crucial to both VHA's ability to oversee the completion of onboarding tasks as well as its ability to identify and make improvements to these processes. We recommended that VHA ensure that regional networks and medical facilities have clear and comprehensive guidance on entering data into USA Staffing, including data-level definitions. VA concurred with our recommendation and identified actions it is taking, such as beginning to develop data-level definitions for upcoming user guides for USA Staffing. VHA estimated that it will complete these efforts in August 2023. In closing, our past work has shown that an agency's workforce plays a central role in transforming an agency into a high-performing organization. However, our recent work has demonstrated staffing challenges in certain VHA programs. Implementing our recommendations would better position VHA to address ongoing and future demand for its Page 12 GAO-23-106836 Related GAO Reports health care services, such as the recent health care expansion for specific categories of toxic-exposed veterans and other eligible veterans under the PACT Act. VHA is taking steps to implement our recommendations; however, without dedicated attention to these efforts, VHA may not be able to ensure it is sufficiently meeting its mission to provide quality and timely care for our nation's veterans. Chairwomen Miller-Meeks and Kiggans, Ranking Member Brownley, Ranking Member Mrvan, and Members of the Subcommittees, this concludes my statement. I would be pleased to respond to any questions that you may have at this time. If you or your staff have any questions about this testimony, please GAO Contact and contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov. Contact Staff points for our Office of Congressional Relations and Public Affairs may be found on the last page of this statement. GAO staff who made key Acknowledgments contributions to this testimony are Rebecca Rust Williamson (Assistant Director) and E. Jane Whipple (Analyst-in-Charge). Other contributors include Jacquelyn Hamilton, Ethiene Salgado-Rodriguez, and Cathy Hamann Whitmore. Page 13 GAO-23-106836 Related GAO Reports Related GAO Reports Veterans Health Administration: Hiring Trends in the U.S. Pacific Territories. GAO-23-105953. Washington, D.C.: February 16, 2023. VA Health Care: VHA Lacks Reliable Onboarding Data for New Clinical Staff. GAO-23-105706. Washington, D.C.: January 25, 2023. Veterans Health Care: Staffing Challenges Persist for Fully Integrating Mental Health and Primary Care Services. GAO-23-105372. Washington, D.C.: December 15, 2022. Federal Hiring: OPM Should Collect and Share COVID-19 Lessons Learned to Inform Hiring During Future Emergencies. GAO-22-104297. Washington, D.C.: October 25, 2021. Veterans Community Care Program: VA Took Action on Veterans' Access to Care, but COVID-19 Highlighted Continued Scheduling Challenges. GAO-21-476. Washington, D.C.: June 28, 2021. Veterans Community Care Program: Improvements Needed to Help Ensure Timely Access to Care. GAO-20-643. Washington, D.C.: September 28, 2020. Veterans Health Administration: Management Attention Is Needed to Address Systemic, Long-standing Human Capital Challenges. GAO-17-30. Washington, D.C.: December 23, 2016. High-Risk Series: An Update. GAO-15-290. Washington, D.C.: February 11, 2015. Page 14 GAO-23-106836 This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. 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