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United States Government Accountability Office: 
GAO: 

Report to the Chairman, Subcommittee on Oversight & Investigations, 
Committee on Veterans' Affairs, House of Representatives: 

October 2014: 

VA Health Care: 

Actions Needed to Ensure Adequate and Qualified Nurse Staffing: 

GAO-15-61: 

GAO Highlights: 

Highlights of GAO-15-61, a report to the Chairman, Subcommittee on 
Oversight & Investigations, Committee on Veterans' Affairs, House of 
Representatives. 

Why GAO Did This Study: 

GAO and others have raised prior concerns about the adequacy and 
qualifications of VHA's nurse staffing. In part to address these 
concerns, VHA issued a directive in 2010 requiring all VAMCs to 
implement a standardized methodology for determining an adequate and 
qualified nurse workforce, which includes developing and executing 
nurse staffing plans. It also requires VAMCs to use the methodology on 
an ongoing basis to evaluate staffing plans. 

GAO was asked to provide information on nurse staffing at VAMCs. This 
report reviews the extent to which (1) VAMCs have implemented VHA's 
nurse staffing methodology, and (2) VHA oversees VAMCs' implementation 
and ongoing administration of the methodology. GAO reviewed documents 
and interviewed officials from VHA, seven VAMCs selected to ensure 
variation in factors such as geographic location, and regional offices 
for these VAMCs. GAO used federal internal control standards to 
evaluate VHA's oversight. GAO also interviewed representatives of 
veterans service organizations, nursing organizations, and unions. 

What GAO Found: 

The seven Department of Veterans Affairs medical centers (VAMC) in 
GAO's review implemented the Veterans Health Administration's (VHA) 
nurse staffing methodology, experienced problems developing and 
executing the related nurse staffing plans, and some reported 
improvements in nurse staffing. Specifically, GAO found that each of 
the seven VAMCs had developed a facility-wide staffing plan-—which 
outlines initiatives needed to ensure appropriate unit-level nurse 
staffing and skill mix-—and taken steps to execute it. However, VAMCs 
experienced problems-—such as lack of data resources and difficulties 
with training-—in both the development and execution of their staffing 
plans. Some VAMC staff reported improvements in the adequacy and 
qualifications of their units' nursing staff when nurse staffing plan 
initiatives were executed. For example, at two VAMCs where the number 
of nurses was increased or where support services for nurses were put 
in place, such as a designated group of staff to assist in 
transporting patients to and from appointments off the unit, unit 
staff said the adequacy of the nursing staff had improved. However, 
some VAMC unit staff reported that unit nurse staffing continued to be 
inadequate and that nurse unit assignments and job duties were not 
always appropriate for their qualifications. 

VHA's oversight is limited for ensuring its nurse staffing methodology 
is implemented and administered appropriately. GAO found the following 
internal controls were limited in VHA's oversight process: 

* Environmental assessment. VHA did not comprehensively assess each 
VAMC to ensure preparedness for implementing the methodology, 
including having the necessary technical support and resources, prior 
to the issuance of the directive requiring each VAMC to implement the 
methodology. 

* Monitoring compliance. VHA does not have a plan for monitoring VAMCs 
to ensure compliance with the implementation and ongoing 
administration of the methodology. 

* Evaluation. VHA has conducted limited evaluations of the 
methodology, and at least one of these evaluations has been 
significantly delayed. 

* Timeliness of communication. VHA's protracted timeline for 
communicating methodology-related information may have hindered the 
ability of VAMCs to appropriately develop their staffing plans and to 
execute the initiatives contained in those plans. 

* Organizational accountability. VHA did not define areas of 
responsibility or establish the appropriate line of reporting within 
VA's management structure for oversight of the implementation and 
ongoing administration of the methodology. 

Without these internal controls in place, VHA cannot ensure its 
methodology meets department goals, such as establishing a 
standardized methodology for determining an adequate and qualified 
nurse workforce at VAMCs, and ultimately, having nurse staffing that 
is adequate to meet veterans' growing and increasingly complex health 
care needs. 

What GAO Recommends: 

GAO recommends VA: (1) assess VAMCs' ability to implement the 
methodology, (2) monitor VAMCs' ongoing compliance with the 
methodology, (3) complete timely evaluations, (4) improve the 
timeliness of communication with VAMCs, and (5) define areas of 
responsibility and reporting within VA's management structure. VA 
concurred with the recommendations. 

View GAO-15-61. For more information, contact Debra A. Draper at (202) 
512-7114 or draperd@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

VAMCs in Our Review Implemented VHA's Nurse Staffing Methodology, 
Experienced Problems Developing and Executing Staffing Plans, and Some 
Reported Improvements in Nurse Staffing: 

VHA's Oversight to Ensure Its Nurse Staffing Methodology Is 
Implemented, Administered Appropriately, and Contributes to an 
Adequate and Qualified Nurse Workforce Is Limited: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Comments from the Department of Veterans Affairs: 

Appendix II: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Types of Nursing Staff Position, Responsibilities, and 
Educational Requirements: 

Table 2: VA Medical Center (VAMC) Status for Development of VAMC-Wide 
Staffing Plan: 

Table 3: Examples of VA Medical Centers' (VAMC) Staffing Plan 
Initiatives: 

Table 4: Examples of Problems VA Medical Centers (VAMC) Experienced 
Developing and Executing Staffing Plans: 

Figures: 

Figure 1: Timeline for Development and Implementation of the Veterans 
Health Administration's (VHA) Nurse Staffing Methodology: 

Figure 2: VA Medical Center (VAMC) Process for Implementing the 
Veterans Health Administration's (VHA) Nurse Staffing Methodology: 

Abbreviations: 

FY: fiscal year: 

LPN: licensed practical nurse: 

NA: nursing assistant: 

NDNQI: National Database of Nursing Quality Indicators: 

NHPPD: nursing hours per patient day: 

OIG: Office of Inspector General: 

ONS: Office of Nursing Services: 

RN: registered nurse: 

VA: Department of Veterans Affairs: 

VAMC: VA medical center: 

VHA: Veterans Health Administration: 

VISN: Veterans Integrated Service Network: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

October 16, 2014: 

The Honorable Mike Coffman: 
Chairman: 
Subcommittee on Oversight & Investigations: 
Committee on Veterans' Affairs: 
House of Representatives: 

Dear Mr. Chairman: 

The Department of Veterans Affairs' (VA) Veterans Health 
Administration (VHA) provides medical care to millions of veterans 
each year. Nurses play an essential role in the medical care that 
veterans receive, and it is critical that VHA has an adequate and 
qualified nursing staff to meet veterans' needs. Studies have shown 
that better care is provided when facilities have both an adequate 
number of nurses, and nurses that are appropriately qualified for the 
jobs to which they are assigned.[Footnote 1] According to VHA, it 
employs more than 80,000 nurses, making it the largest employer of 
nurses in the country. The number of veterans receiving care at VA 
medical centers (VAMC) increased from 5.2 million in fiscal year (FY) 
2009 to 5.8 million in FY 2013, and VHA estimates that it will serve 
close to 8.8 million veterans by 2020. Furthermore, more intensive 
nursing care is being required by a growing number of veterans 
returning from military operations in Afghanistan and Iraq, and by 
aging veterans from prior eras of service. 

For more than 10 years, concerns have been raised that VHA might not 
have an adequate and qualified nursing staff to care for the 
increasing number of veterans requiring more complex care. In 2002, 
Congress passed legislation requiring VA to develop a nationwide 
policy on staffing levels for the operation of VAMCs.[Footnote 2] 
Specifically, the law required VA to establish a nationwide policy on 
the staffing of VAMCs to ensure they have adequate staff, taking into 
account staffing levels and the mixture of staff skills required for 
providing care to veterans. The need for a new nurse staffing policy 
was highlighted in 2004 when VA's Office of Inspector General (OIG) 
issued a report raising concerns about the adequacy of nurse staffing 
levels in VAMCs' inpatient units.[Footnote 3] By 2008, however, no 
national policy on nurse staffing had been implemented. In October 
2008, we issued a report raising concerns about the adequacy of nurse 
staffing, specifically for registered nurses (RN) in inpatient units, 
and the need to expeditiously proceed with developing and implementing 
a new nurse staffing system, among other issues.[Footnote 4] We 
recommended that VHA develop a detailed plan for implementing a new 
nurse staffing system and ensure it provided accurate nurse staffing 
estimates. In part to address these concerns, in 2010, VHA issued a 
directive requiring each VAMC to implement a nationally standardized 
methodology for determining an adequate and qualified nurse workforce, 
which includes the development and execution of nurse staffing plans. 
The staffing plans outline initiatives needed to ensure appropriate 
nurse staffing levels and skill mix in units to support high-quality 
patient care in the most effective manner possible. The directive also 
requires VAMCs to use the methodology on an ongoing basis to evaluate 
staffing plans at least annually. 

You expressed interest in obtaining information on nurse staffing at 
VAMCs. In this report, we review the extent to which (1) VAMCs have 
implemented VHA's nurse staffing methodology, and (2) VHA oversees 
VAMCs' implementation and ongoing administration of its nurse staffing 
methodology. 

To determine the extent to which VAMCs have implemented VHA's nurse 
staffing methodology, we reviewed documents and interviewed officials 
from VHA. Specifically, we reviewed information and interviewed 
officials from VHA's Office of Nursing Services (ONS)--the VHA office 
responsible for providing national policies, guidelines, and oversight 
for all VAMC nursing personnel--on the extent to which VAMCs have 
implemented the methodology in inpatient units (Phase I); VAMCs have 
piloted the methodology in operating room, emergency department, and 
spinal cord injury units (Phase II); and VHA has developed plans for 
an automatic staffing system (Phase III). We interviewed officials and 
nursing staff from seven VAMCs located in: (1) Battle Creek, Michigan; 
(2) Bronx, New York; (3) Columbia, South Carolina; (4) Dallas, Texas, 
(5) Fort Harrison, Montana; (6) San Diego, California; and (7) Tampa, 
Florida about their experiences implementing VHA's nurse staffing 
methodology. These VAMCs were selected to ensure variation in factors 
such as geographic location, rural versus urban location, complexity, 
[Footnote 5] RN turnover rate, and Magnet status.[Footnote 6] We did 
not independently assess the extent to which the VAMCs' implementation 
of the staffing methodology contributed to an adequate and qualified 
workforce. Furthermore, the results of our review of the seven VAMCs 
are not generalizable across all VAMCs. We reviewed literature and 
interviewed researchers who have published in the area of nurse 
staffing, representatives of selected veterans service organizations, 
[Footnote 7] and representatives of selected nursing organizations and 
unions[Footnote 8] to gain their perspectives about the current 
environment for nurse staffing, nurse staffing methodologies in 
general, and VHA's nurse staffing methodology. 

To determine the extent to which VHA oversees VAMCs' implementation 
and ongoing administration of its nurse staffing methodology, we 
reviewed documents and interviewed officials from VHA. Specifically, 
we reviewed VHA documents, such as national directives, policies, and 
evaluation plans, to determine the extent to which VHA has provided 
VAMCs guidance regarding the implementation and ongoing administration 
of the staffing methodology. We interviewed officials from ONS, the 
seven VAMCs in our review, and the regional Veterans Integrated 
Service Networks (VISN)[Footnote 9] for these seven VAMCs regarding 
their oversight of VAMCs' implementation of the staffing methodology. 
We also interviewed ONS officials and VAMC officials and staff about 
the extent to which VAMCs' implementation of the staffing methodology 
contributes to an adequate and qualified nurse workforce. To determine 
whether VHA applied appropriate internal controls in its oversight of 
the nurse staffing methodology, we used relevant criteria from federal 
internal control standards. We also used relevant strategic planning 
and performance measures from the Government Performance and Results 
Act as enhanced by the Government Performance and Results 
Modernization Act of 2010, as incorporated in GAO's guidance on 
assessing performance.[Footnote 10] 

We conducted this performance audit from September 2013 to October 
2014 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. 

Background: 

Nurse staffing is a critical part of health care because of the 
effects it can have on patient outcomes and nurse job satisfaction. 
According to VHA, its staffing methodology aims to maximize nurses' 
productivity and efficiency, while providing safe patient care by 
ensuring appropriate nurse staffing levels and skill mi[Check]. 

VHA Nurse Workforce: 

VHA's nurse workforce is primarily composed of RNs,[Footnote 11] 
licensed practical nurses (LPN),[Footnote 12] and nursing assistants 
(NA). These nurses provide care--ranging from primary care to complex 
specialty care--in inpatient, outpatient, and residential care 
settings at 151 VAMCs across the country.[Footnote 13] In addition to 
the size of the nursing workforce, the nursing skill mix--i.e., the 
share of each type of nurse (RNs, LPNs, or NAs) of the total--is an 
important component of nurse staffing. Units vary in their nursing 
skill mix, depending on the needs of their patients. For example, 
intensive care units require higher intensity nursing, and may have a 
skill mix that is primarily composed of RNs compared to other types of 
nursing units that may provide less complex care. (See table 1 for a 
general description of the types of nursing staff position, 
responsibilities, and educational requirements.) 

Table 1: Types of Nursing Staff Position, Responsibilities, and 
Educational Requirements: 

Position type: Registered nurse (RN); 
Responsibilities: Assesses and provides care to patients, administers 
medications; documents patients' medical conditions, including 
admissions and discharges; analyzes test results; establishes 
treatment plans; and operates medical equipment; 
Educational requirements: Highest educational requirements: Has 
completed a nursing education program, met state licensing 
requirements, and passed a nurse licensing examination to obtain an RN 
license. 

Position type: Licensed practical nurse (LPN)[A]; 
Responsibilities: Takes patient vital signs, provides basic care, and 
administers medications, but generally does not provide certain 
complex patient care services such as patient assessments or 
administration of intravenous medications; 
Educational requirements: Fewer educational requirements than RNs: 
Has a high school diploma or its equivalent and passed a licensing 
examination upon completion of a state-approved program available at 
technical schools and community colleges, typically lasting 1 year. 

Position type: Nursing assistant; 
Responsibilities: Attends to basic patient needs such as providing 
personal care to patients (e.g., assistance with bathing, dressing, 
and personal hygiene), carries out non-specialized duties (e.g., 
measure blood pressure), and supports other nursing staff; 
Educational requirements: Less extensive educational requirements than 
RNs and LPNs: Has registered as a nursing assistant with their state 
health department, and passed a written competency examination upon 
completion of a state-approved training program, generally lasting 3 
to 12 weeks. 

Source: VHA, nursing organizations, and literature. GAO-15-61. 

[A] LPNs and licensed vocational nurses have the same level of 
education and patient care responsibilities. In this table, when we 
refer to LPNs, we are referring to both LPNs and licensed vocational 
nurses. 

[End of table] 

Although the number of nurses at VAMCs increased from FY 2009 to FY 
2013, VHA ranked nurses as the second most challenging occupation to 
recruit and retain. Specifically, the total number of nurses at VAMCs 
increased 13 percent from 72,542 in FY 2009 to 81,940 in FY 2013, with 
similarly proportionate increases within each position type--RN, LPN, 
and NA. During the same time period, the annual nurse turnover rate at 
VAMCs--the percentage of nurses who left VHA through retirement, 
death, termination, or voluntary separation--increased from 6.6 
percent to 8.0 percent. Although RNs had the lowest turnover rate 
among nurses, VHA noted particular difficulty recruiting and retaining 
for the position, particularly for RNs with advanced professional 
skills, knowledge, and experience, such as RNs that provide services 
in medical and surgical care units.[Footnote 14] VHA projects that 
approximately 40,000 new nurses will be needed through FY 2018 to 
maintain current staffing levels and to meet the needs of veterans. 

VHA's Nurse Staffing Methodology: 

To help ensure adequate and qualified nurse staffing at VAMCs, in July 
2010, VHA issued VHA Directive 2010-034: Staffing Methodology for VHA 
Nursing Personnel. ONS, the VHA office responsible for providing 
national policies and guidelines for all VHA nursing personnel, led 
the development of the nurse staffing methodology, which began in 
2007. (See figure 1.) 

Figure 1: Timeline for Development and Implementation of the Veterans 
Health Administration's (VHA) Nurse Staffing Methodology: 

[Refer to PDF for image: timeline] 

July 2007: 

Office of Nursing Services (ONS) developed a preliminary literature 
review and conducted a national nursing strategic planning meeting of 
nursing representatives from across VHA. 

February 2008: 
ONS established a Staffing Methodology Group Steering Committee that 
developed recommendations, strategies, and tools to implement a pilot 
for the staffing methodology. 

November 2008: 
ONS piloted Phase I in inpatient units at 37 VA medical centers (VAMC). 

September 2009: 
ONS completed an evaluation of the Phase I pilot. 

July 2010: 
VA issued its staffing methodology directive to provide a nationally 
standardized method of determining an adequate and qualified nurse 
workforce. 

September 2011: 
VHA's deadline for all VAMCs to have implemented Phase I of the 
staffing methodology. 

2013: 
ONS piloted Phase II in the emergency department, operating room, and 
spinal cord injury units of 26 VAMCs. 

October 2014: 
VHS's deadline for all VAMCs to have implemented Phase II of the 
staffing methodology in operating rooms only. No deadlines have been 
set for the implementation of Phase II in emergency department and 
spinal cord injury units, or Phase III, an automated staffing system. 

Source: VHA. GAO-15-61. 

[End of figure] 

To implement the methodology, each VAMC is required to (1) develop a 
VAMC-wide staffing plan for its nurse workforce, comprised of 
individual unit-level staffing plans, and (2) execute that plan. (See 
figure 2 for an outline of the process for implementing VHA's nurse 
staffing methodology.) 

Figure 2: VA Medical Center (VAMC) Process for Implementing the 
Veterans Health Administration's (VHA) Nurse Staffing Methodology: 

[Refer to PDF for image: process illustration] 

Development: 

Unit Expert Panels: 
Developing staffing plans utilizing the analysis of each unit's 
nursing hours per patient day data, and present staffing plans to 
facility expert panel. 

Facility Expert Panel: 
Reviews each unit's staffing plan, including analyses of nursing hours 
per patient day and unit recommendations for staffing, which will 
become actionable initiatives after final approval. Aggregates all 
unit plans into a VAMC-wide staffing plan. 

VAMC Nurse Executive: 
Reviews VAMC-wide staffing plan and forwards to VAMC director for 
review and approval. 

VAMC Director: 
Reviews and approves final VAMC-wide staffing plan. 

Execution: 

VAMC:
Executes initiatives in approved VAMC-wide staffing plan. 

Source: VHA. GAO-15-61. 

[End of figure] 

Each VAMC unit is to develop a staffing plan outlining recommendations 
on the appropriate nurse staffing levels and skill mix needed in that 
unit to support high-quality patient care in the most effective manner 
possible. Specifically, staffing plans are to be developed using 
expert panels and a data-driven analysis of nursing hours per patient 
day (NHPPD). VAMC nurse executives—members of senior management within 
each VAMC—are responsible for implementing the staffing methodology in 
their respective VAMCs. 

* Expert panels: advisory groups—at the unit and facility level—of 
VAMC staff with in-depth knowledge of nurse staffing needs. The use of 
expert panels is intended to apply principles of shared governance, 
which allows nurses to have influence over the delivery of patient 
care and involves stakeholders from across the VAMC. VAMC nurse 
executives are responsible for ensuring that the unit-based expert 
panels represent all nursing types (RN, LPN, NA) and developing the VAMC
's facility expert panel. 

* Data-driven analysis of NHPPD: involves determining the number and 
skill mix of nurses needed for each unit by calculating the number of 
direct patient care nursing hours provided for all patients on that 
unit during a 24-hour period.[Footnote 15] The use of NHPPD represents 
a move away from the more traditional nurse-to-patient ratios that 
assign a certain number of patients to each nurse. Some research 
suggests that NHPPD can better capture changes in nurses' workloads 
and case mix resulting from admissions and discharges, as well as 
patient acuity levels, which can impact the amount of time nurses 
spend with each patient.[Footnote 16] 

After developing the staffing plan, each unit-based expert panel 
presents its plan, which includes staffing recommendations, to the VAMC'
s facility expert panel. Those staffing recommendations may include, 
for example, initiatives to change the number and skill mix of nurses 
needed for each shift; change the number of nurses required for 
coverage during predicted absences, such as annual and sick leave; and 
develop support services for nurses, such as designated individuals to 
transport patients to other areas of the facility as needed. The 
facility expert panel—comprised of staff from across the VAMC—reviews 
each unit-based panel's staffing plan and aggregates all of the unit 
plans into one VAMC-wide staffing plan. The VAMC nurse executive 
reviews the VAMC-wide staffing plan and forwards it to the VAMC 
director for review and approval. Once approved, the VAMC then begins 
execution of the initiatives outlined in the VAMC-wide staffing plan. 
The directive requires each VAMC to conduct an ongoing staffing 
analysis to evaluate staffing plans annually, at a minimum, and for 
VAMC directors to incorporate projected staffing needs into their 
annual budget review. 

The staffing methodology is being implemented in three phases. 

* In Phase I, VAMCs were to implement the staffing methodology in all 
inpatient units no later than September 30, 2011. 

* In Phase II, VAMCs are to implement the staffing methodology for all 
other units, including the operating room, emergency department, and 
spinal cord injury units.[Footnote 17] ONS has completed the Phase II 
pilot for operating room units, and VAMCs are expected to implement 
the methodology in their operating room units by October 1, 2014. 
Deadlines for the implementation in other Phase II units have not been 
set. 

* In Phase III, VAMCs are to use an automated system developed by VHA 
that (1) merges VHA staffing data used in the staffing methodology and 
other VHA data, such as human resource data, into one data system, and 
(2) incorporates the data into staffing-related reports, such as 
quality-of-care reports. A deadline for Phase III implementation has 
not been set. 

In May 2014, the VA OIG found that VAMCs in its review varied in their 
implementation of the staffing methodology. Specifically, the VA OIG 
reported that 8 of the 28 VAMCs reviewed had not fully implemented all 
components of the staffing methodology by September 2013, 2 years past 
the implementation date required by the VHA directive.[Footnote 18] As 
these findings were similar to those of its April 2013 report, 
[Footnote 19] the VA OIG stated in its 2014 report, “We re-emphasize 
the need for all facilities to fully implement the methodology and 
accurately address patient needs with safe and adequate staffing.” 

Impact of Nurse Staffing on Patient Outcomes and Nurse Job 
Satisfaction: 

Adequate and qualified nurse staffing at VAMCs is required to provide 
effective and continuous patient care and to maintain a stable and 
engaged workplace. The importance of nurse staffing on patient 
outcomes and nurse job satisfaction has been emphasized by various 
entities, including The Joint Commission;[Footnote 20] American Nurses 
Association;[Footnote 21] Institute of Medicine;[Footnote 22] and 
Agency for Healthcare Research and Quality.[Footnote 23] Additionally, 
research has linked the adequacy and qualifications of nurse staffing 
to patient outcomes and nurse job satisfaction. For example, studies 
have shown: 

* A link between the adequacy of nurse staffing and patient outcomes, 
particularly in inpatient units, such as intensive care and surgical 
units. For example, medication errors, pressure ulcers, hospital 
acquired infections, pneumonia, longer-than-expected stays, and higher 
mortality rates each have been associated with inadequate nurse 
staffing.[Footnote 24] 

* A link between the qualifications of nursing staff and patient 
outcomes. For example, one study found that patients cared for in 
units utilizing more licensed and experienced nursing staff (RNs and 
LPNs) and fewer unlicensed aides (NAs) had shorter lengths of stay.
[Footnote 25 Other studies linked baccalaureate-prepared nurses to 
lower mortality rates.[Footnote 26 

* A link between nurse staffing and job satisfaction. For example, 
some studies have linked low job satisfaction to heavy workloads and 
an inability to ensure patient safety.[Footnote 27] Other studies 
found that improving nurse staffing and working conditions may 
simultaneously reduce nurses' burnout, risk of turnover, and the 
likelihood of medical errors, while increasing patients' satisfaction 
with their care.[Footnote 28] 

Non-VA health care organizations use various approaches to ensure 
effective nurse staffing. For example, some use fixed nurse-to-patient 
ratios while others use adjustable, unit-specific minimum staffing 
levels,[Footnote 29] and there have been several efforts to address 
nurse staffing using these different approaches.[Footnote 30] For 
example, California has enacted legislation requiring regulations that 
mandate specific nurse-to-patient ratios that limit the number of 
patients cared for by an individual nurse. Other states have passed 
legislation or adopted regulations addressing nurse staffing without 
mandating specific ratios or staffing levels. For example, some states 
require hospitals to have committees responsible for developing unit 
staffing plans or require public reporting of staffing. 

VAMCs in Our Review Implemented VHA's Nurse Staffing Methodology, 
Experienced Problems Developing and Executing Staffing Plans, and Some 
Reported Improvements in Nurse Staffing: 

All seven VAMCs in our review developed staffing plans using VHA's 
nurse staffing methodology and have taken steps to execute them. 
However, VAMCs experienced problems in both the development and 
execution of their staffing plans. Improvements in nurse staffing were 
reported by some of the VAMCs which had taken steps to execute the 
staffing plans. 

VAMCs in Our Review Have Implemented VHA's Nurse Staffing Methodology 
by Developing Staffing Plans and Taking Steps to Execute Them: 

The seven VAMCs in our review have implemented VHA's nurse staffing 
methodology; specifically, each of these VAMCs has developed a 
facility-wide staffing plan, comprised of unit-level staffing plans 
for inpatient units, and has taken steps to execute it.[Footnote 31] 
Although each of the seven VAMCs in our review developed a staffing 
plan for FY 2013, only one had developed a plan per VHA's directive—
that is, used both expert panels and analysis of NHPPD—by September 
30, 2011, the deadline specified in the directive. (See table 2.) 
Across all 151 VAMCs, according to ONS officials, VAMCs' 
implementation of the nurse staffing methodology varied, with, for 
example, some VAMCs completing the development of their staffing plans 
during FY 2013, and some only beginning the development process. 

Table 2: VA Medical Center (VAMC) Status for Development of VAMC-Wide 
Staffing Plan: 

VAMC: A; 
Status: 
FY 2011: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive; 
FY 2012: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive; 
FY 2013: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive. 

VAMC: B; 
Status: 
FY 2011: VAMC-wide staffing plan not complete per VHA directive; 
FY 2012: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive; 
FY 2013: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive. 

VAMC: C; 
Status: 
FY 2011: VAMC-wide staffing plan not complete per VHA directive; 
FY 2012: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive; 
FY 2013: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive. 

VAMC: D; 
Status: 
FY 2011: VAMC-wide staffing plan not complete per VHA directive; 
FY 2012: VAMC-wide staffing plan not complete per VHA directive; 
FY 2013: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive. 

VAMC: E; 
Status: 
FY 2011: VAMC-wide staffing plan not complete per VHA directive; 
FY 2012: VAMC-wide staffing plan not complete per VHA directive; 
FY 2013: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive. 

VAMC: F; 
Status: 
FY 2011: VAMC-wide staffing plan not complete per VHA directive; 
FY 2012: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive; 
FY 2013: VAMC-wide staffing plan complete per Veterans Health 
Administration (VHA) directive. 

VAMC: G; 
Status: 
FY 2011: VAMC-wide staffing plan not complete per VHA directive; 
FY 2012: [Empty]; 
FY 2013: [Empty]. 

Source: Seven VAMCs in our review. GAO-15-61. 

Note: VHA Directive 2010-034 required each VAMC to develop a VAMC-wide 
staffing plan for use in its inpatient units by September 30, 2011. 
The process for developing the staffing plans included the use of 
expert panels--at the unit level and at the facility level--and a data-
driven analysis of nursing hours per patient day. 

[End of table] 

In addition to developing staffing plans, all seven VAMCs in our 
review had taken steps to execute their respective staffing plans. For 
example, VAMCs had taken steps to execute initiatives to increase the 
number of unit nurses or change the skill mix of nurses to address 
patient care needs. (See table 3 for examples of VAMCs' staffing plan 
initiatives.) VAMC officials told us there are many factors that could 
affect the execution of staffing plan initiatives, such as available 
resources, the amount of time needed, and other strategic priorities. 

Table 3: Examples of VA Medical Centers' (VAMC) Staffing Plan 
Initiatives: 

Initiative: Number of nurses; 
Description: Increase the total number of unit nurses--for example, 
registered nurses (RN), licensed practical nurses (LPN), or nursing 
assistants (NA)--to meet direct patient care needs. 

Initiative: Skill mix; 
Description: Change skill mix of nurses to better meet patient needs--
particularly having more RNs (rather than LPNs) to conduct timely 
patient assessments. 

Initiative: Contract nurse pool; 
Description: Develop contracts to use temporary nursing staff from 
external employment organizations to meet short-term staffing needs. 

Initiative: Float pool; 
Description: Develop designated group of nurses to float to units on 
an as-needed basis. 

Initiative: Sitter pool; 
Description: Develop designated group of staff to provide one-on-one 
direct patient observation to allow nurses to better care for a 
broader group of patients. 

Initiative: Transport team; 
Description: Develop designated group of staff to assist in 
transporting patients to and from appointments off the unit so that 
RNs are able to remain on the unit. 

Initiative: Staff reassignment; 
Description: Reassign nursing staff from an overstaffed unit to an 
understaffed unit. 

Initiative: Patient census; 
Description: Temporarily reduce patient census by closing beds because 
of inadequate staffing. 

Source: Seven VAMCs in our review. GAO-15-61. 

[End of table] 

VAMCs Experienced Problems Developing and Executing Staffing Plans, 
and Many of These Problems Persist: 

Officials and nursing staff from the seven VAMCs in our review told us 
they experienced problems developing and executing staffing plans. 
(See table 4 for examples of problems.) Some VAMCs were able to devise 
solutions; however in many cases, the problems have persisted. 

Table 4: Examples of Problems VA Medical Centers (VAMC) Experienced 
Developing and Executing Staffing Plans: 

VAMC: A; 
Problems developing staffing plans: Lack of necessary data resources: 
Lack of necessary data resources: [Empty]; 
Difficulty completing and understanding training: [Check]; 
Problems executing staffing plans: Time required: [Check]; 
Lack of communication within VAMC: [Empty]; 
Difficulty integrating unit staff in expert panels: [Empty]; 
Problems executing staffing plans: 
Hiring delays: [Check]; 
Budget constraints: [Check]. 

VAMC: B; 
Problems developing staffing plans: Lack of necessary data resources: 
Lack of necessary data resources: [Check]; 
Difficulty completing and understanding training: [Check]; 
Problems executing staffing plans: Time required: [Check]; 
Lack of communication within VAMC: [Check]; 
Difficulty integrating unit staff in expert panels: [Check]; 
Problems executing staffing plans: 
Hiring delays: [Check]; 
Budget constraints: [Check]. 

VAMC: C; 
Problems developing staffing plans: Lack of necessary data resources: 
Lack of necessary data resources: [Check]; 
Difficulty completing and understanding training: [Empty]; 
Problems executing staffing plans: Time required: [Check]; 
Lack of communication within VAMC: [Check]; 
Difficulty integrating unit staff in expert panels: [Check]; 
Problems executing staffing plans: 
Hiring delays: [Check]; 
Budget constraints: [Check]. 

VAMC: D; 
Problems developing staffing plans: Lack of necessary data resources: 
Lack of necessary data resources: [Check]; 
Difficulty completing and understanding training: [Check]; 
Problems executing staffing plans: Time required: [Check]; 
Lack of communication within VAMC: [Check]; 
Difficulty integrating unit staff in expert panels: [Empty]; 
Problems executing staffing plans: 
Hiring delays: [Check]; 
Budget constraints: [Check]. 

VAMC: E; 
Problems developing staffing plans: Lack of necessary data resources: 
Lack of necessary data resources: [Check]; 
Difficulty completing and understanding training: [Check]; 
Problems executing staffing plans: Time required: [Check]; 
Lack of communication within VAMC: [Empty]; 
Difficulty integrating unit staff in expert panels: [Empty]; 
Problems executing staffing plans: 
Hiring delays: [Check]; 
Budget constraints: [Check]. 

VAMC: F; 
Problems developing staffing plans: Lack of necessary data resources: 
Lack of necessary data resources: [Check]; 
Difficulty completing and understanding training: [Check]; 
Problems executing staffing plans: Time required: [Check]; 
Lack of communication within VAMC: [Check]; 
Difficulty integrating unit staff in expert panels: [Check]; 
Problems executing staffing plans: 
Hiring delays: [Check]; 
Budget constraints: [Empty]. 

VAMC: G; 
Problems developing staffing plans: Lack of necessary data resources: 
Lack of necessary data resources: [Check]; 
Difficulty completing and understanding training: [Check]; 
Problems executing staffing plans: Time required: [Check]; 
Lack of communication within VAMC: [Empty]; 
Difficulty integrating unit staff in expert panels: [Empty]; 
Problems executing staffing plans: 
Hiring delays: [Empty]; 
Budget constraints: [Empty]. 

Source: Seven VAMCs in our review. GAO-15-61. 

[End of table] 

Problems Developing Staffing Plans. Staff and officials from each of 
the seven VAMCs in our review reported facing problems developing 
staffing plans. 

* Lack of necessary data resources. Staff and officials at six of the 
seven VAMCs in our review said they did not have the appropriate data 
resources to effectively calculate NHPPD as required by VHA's staffing 
methodology directive. Specifically, the directive instructs VAMC 
staff to calculate NHPPD using a wide range of data, such as number of 
admissions, transfers, and discharges; hours used for planning and 
treatment; and human resources data. We found that staff and officials 
needed to use multiple sources to collect the necessary data, in some 
cases manually, a process they said was time-consuming and potentially 
error-prone, and required data expertise they did not always have. For 
example, at one VAMC, the staffing methodology coordinator—-a VAMC 
official who assists with the administrative tasks associated with the 
implementation process—-told us she struggled with some data analysis 
techniques, such as creating a spreadsheet to help track staffing 
data, but the VAMC did not have the financial resources to hire 
additional data analysts to support the methodology. In contrast, 
officials from two VAMCs in our review told us staffing methodology 
coordinators were assigned in part based on their data analysis 
expertise. 

* Difficulty completing and understanding training. Staff from six of 
the seven VAMCs in our review said the ONS training on the methodology 
was time consuming to complete, and difficult to understand. In 2011, 
ONS switched from instructor-led, group training to individual, 
computer-based PowerPoint training. Many unit staff reported that 
because the computer-based training took many hours to complete, it 
was difficult to find the time to complete it, while also carrying out 
their patient care responsibilities. They told us they often had to 
start and stop the training to attend to patients, which diminished 
its effectiveness. Further, the course's complex material was hard to 
absorb through an individual, computer-based course, with many staff 
suggesting their understanding would have been greatly improved with 
an instructor-led, group course where they could ask questions, ensure 
consistency of learning, and build camaraderie among unit expert panel 
members. To address the difficulties in completing and understanding 
the training, one VAMC developed its own instructor-led, group 
training provided to all its units. 

* Time required. Staff and officials at all seven of the VAMCs in our 
review reported that developing staffing plans required a lot of staff 
time due to the complexity of the process. In particular, they said 
gaining an understanding of the methodology, collecting the necessary 
data, convening the unit expert panels, and preparing presentations 
for the facility expert panel were time-intensive tasks that, in some 
circumstances, took time away from patient care. For example, members 
from one unit expert panel estimated they spent, in total, about 160 
hours (4 weeks) developing the unit staffing plan during the first 
year the staffing methodology was implemented in their unit. Some VAMCs'
 staffing methodology coordinators developed specific processes 
designed to decrease the burden on nursing staff and improve 
efficiency. For example, they created templates for unit panel members 
to use in staffing plan development; such templates improved 
efficiency because unit panel members did not have to independently 
develop their presentation format. Further, facility expert panel 
members had to orient themselves to only one template, and were 
therefore able to more easily make facility-level comparisons and 
decisions. 

* Lack of communication within VAMC. Unit expert panel members at four 
of the seven VAMCs in our review said there was a lack of 
communication between nurses and VAMC leadership regarding the status 
of the staffing plans, including plans for execution of the staffing 
plan initiatives. Staff at one of these VAMCs said they had not 
received any feedback on their FY 2012 or FY 2013 unit staffing plans; 
they added that developing the 2013 staffing plan without getting any 
feedback on the prior year's plan felt “frustrating.” In contrast, at 
another VAMC, officials told us that all unit staff—not just staff 
involved in the unit panel—received regular updates on the nurse 
staffing process at their monthly unit staff meetings. 

* Difficulty integrating unit staff into expert panels. Staff and 
officials at three VAMCs described challenges in integrating unit 
staff into expert panels. Some unit panel members told us that 
although they were considered members of their respective unit panels, 
they were not significantly involved in the development of their units'
staffing plans. For example, a unit panel member said the VAMC's 
staffing methodology coordinator calculated the unit's NHPPD, 
developed the corresponding unit staffing plan, and presented the unit 
staffing plan to the respective facility expert panel almost entirely 
without her unit's input. As a result, there was limited involvement 
of the unit panel members in the expert panel and, consequently, 
limited shared governance. Officials at these VAMCs said that from 
their perspectives, there was interest in the methodology among unit 
panel members, but sometimes it was difficult for these staff to 
attend relevant meetings because of patient needs. In contrast, unit 
panel members at other VAMCs in our review described how they were 
fully integrated into the unit panels. They described in detail the 
data analyses they prepared, the meetings they participated in, and 
their experiences presenting their unit staffing plans to the facility 
expert panel. Members from one unit panel told us it was helpful to be 
able to use data to validate the unit's staffing and share this data 
with the facility expert panel—VAMC staff “beyond the typical chain of 
command.” Officials at this VAMC noted that unit panel members felt 
“empowered” to present their work to the facility expert panels. 

Problems Executing Staffing Plans. Staff and officials from six of the 
seven VAMCs in our review noted problems executing staffing plans once 
approved by the VAMC director. 

* Hiring delays. Staff and officials from six of the seven VAMCs in 
our review said they often faced hiring delays that impacted their 
ability to execute staffing plan initiatives. Some VAMC staff noted it 
could take more than 6 months to fill unit vacancies. Although staff 
from one VAMC said hiring was slowed by the dearth of qualified nurses 
in their community, staff from other VAMCs in our review said the 
supply of nurses was not the problem, but rather the problem was the 
VHA hiring process, which took months to complete for each candidate. 
Additionally, VAMC staff noted that new hires also needed to complete 
necessary internal trainings before joining a unit full time, which 
added to the delays, and that some new hires were hurried through this 
training process because their units were so desperate to have them on 
staff. 

* Budget constraints. Staff and officials from five of the seven VAMCs 
in our review said their VAMCs were not able to fully execute their 
staffing plans due to budget constraints. For example, at one VAMC, 
one of the approved staffing plan initiatives was the hiring of a 
large number of nurses for its units, in part, to address the VAMC's 
inability to increase their nursing staff over a period of years. The 
official told us that, due to budget constraints, the VAMC was going 
to phase in this hiring initiative over the next few years. 

Improvements in Nurse Staffing Were Reported When VAMCs Executed 
Staffing Plan Initiatives: 

Some VAMC staff reported improvements in the adequacy and 
qualifications of their units' nursing staff when nurse staffing plan 
initiatives were executed. For example, at two VAMCs at which the 
number of nurses was increased or support services for nurses, such as 
patient transporters or sitters, were put in place,[Footnote 32] unit 
staff said the adequacy of the nursing staff had improved. 
Furthermore, improvements in the qualifications of unit nursing staff 
were noted by staff in VAMC units where, for example, skill-mix 
changes were made or the amount of floating of nurses from their home 
unit to an unfamiliar unit was decreased. Both VAMC officials and unit 
staff noted improvements in staffing when nurses' qualifications were 
more appropriately matched to the right level of work (for example, 
having RNs rather than LPNs available to provide more complex patient 
care) and to the right units (for example, the units for which they 
were hired and trained). 

Some VAMC staff said they also had seen improvements in patient 
outcomes and nurse job satisfaction. For example, nursing staff at one 
VAMC said that after creating sitter positions—as indicated by their 
VAMC's staffing plan—they saw a decrease in patient falls. The staff 
said sitters were able to monitor patients more closely, and as a 
result, patients were less likely to fall during walks to the 
bathroom, for example. Similarly, nursing staff in a mental health 
unit at another VAMC said that by having more staff they had decreased 
their restraint use because there were more staff available to meet 
veterans' needs. Additionally, nursing staff we interviewed at one 
VAMC that had made staffing changes based on staffing plans said they 
were better able to provide the type of nursing care “veterans deserve,”
and this made them feel more positive about their work. Some nurses at 
this VAMC also said the shared governance aspect of the methodology 
was empowering, which, combined with their enhanced understanding of 
staffing at their VAMC, helped improve their overall job satisfaction. 

However, some VAMC unit staff reported that unit nurse staffing 
continued to be inadequate and that nurse unit assignments and job 
duties were not always appropriate for their qualifications. For six 
of the VAMCs in our review, staff from at least one unit interviewed 
said their unit staffing levels were inadequate. Staff said ensuring 
adequate staffing was particularly challenging when there were 
unplanned staff absences and they had to “scramble” to provide 
coverage. Some unit staff noted that this situation often resulted in 
units forcing nurses to work overtime or nurses floating to other 
units where they did not always have the qualifications to provide 
care. At some VAMCs, staff said there were increased staff injuries 
due to inadequate staffing. Furthermore, staff at one VAMC reported 
that where there had not been any changes made based on the unit 
staffing plans, their units continued to be understaffed to the 
detriment of both patient care and their job satisfaction. 

VHA's Oversight to Ensure Its Nurse Staffing Methodology Is 
Implemented, Administered Appropriately, and Contributes to an 
Adequate and Qualified Nurse Workforce Is Limited: 

Our review of VHA's oversight of its nurse staffing methodology found 
that some internal controls—those related to environmental assessment, 
a plan for monitoring compliance, evaluation, timeliness of 
communication, and organizational accountability—are limited. The 
implementation of internal controls is necessary for ensuring 
initiatives achieve intended outcomes and for minimizing operational 
problems. Without these internal controls in place, VHA cannot ensure 
that its methodology meets department goals, such as establishing a 
standardized methodology for determining adequate and qualified nurse 
staffing at all VAMCs, and ultimately, having nurse staffing that is 
adequate to meet veterans' health care needs. 

Environmental Assessment. VHA did not comprehensively assess each VAMC 
to ensure preparedness for implementing its methodology, including 
having the necessary technical support and resources, prior to the 
issuance of the methodology directive in 2010. Furthermore, as of 
August 2014, VHA did not have a plan for assessing whether VAMCs have 
the necessary resources to execute their approved nurse staffing 
plans. Under federal internal control standards, successful 
organizations monitor their internal and external environments 
continuously and systematically, and by building environmental 
assessments into the strategic planning process, are able to stay 
focused on long-term goals even as they make changes to achieve them. 

VHA did not assess VAMCs' technical resources to determine if all 
VAMCs would be able to successfully implement the methodology. For 
example, the directive recommended that VAMCs use comparative data 
from external sources, such as the National Database of Nursing 
Quality Indicators (NDNQI) when analyzing unit-level staffing data. 
According to some VAMC officials, due to the costs and complexity of 
contracting,[Footnote 33] not all VAMCs had access to this data 
source.[Footnote 34] Each VAMC was responsible for establishing its 
own contract to purchase access to NDNQI data, which some VAMC 
officials said was expensive and time-consuming to set up, noting that 
it would have been helpful to have assistance in coordinating the 
contracting process. Officials from ONS reported that they are 
discussing the possibility of having a VHA-wide contract so that all 
VAMCs would have access to NDNQI data. In addition to access to 
comparative data, according to the directive, VAMCs need appropriate 
data system capabilities—in particular an automated staffing system 
for information such as patient admission, transfer and discharge 
data, and human resources data—to facilitate implementation of the 
data-driven methodology and calculation of NHPPD. However, not all 
VAMCs in our review had an automated staffing system in place even 3 
years after the release of the directive. Officials at a VAMC without 
an automated staffing system told us staff were collecting and 
inputting data, in many cases manually, into a spreadsheet to 
calculate NHPPD, and that this process was extremely time-consuming 
and potentially error-prone. ONS officials said they knew VAMCs needed 
automated staffing systems when the directive was published in 2010. 
However, they thought Phase III-—a national automated staffing system—-
would be forthcoming, and did not fully review whether VAMCs had 
alternative data capabilities to assist them in the interim. 

When we asked how they assessed the readiness of VAMCs for 
implementation of the methodology, ONS officials told us that they did 
not do this as well as they should have for Phase I implementation in 
inpatient units, despite its 2009 Phase I pilot evaluation to better 
understand the potential capabilities and weaknesses of VAMCs. 
According to ONS, it still has not conducted such an assessment of all 
VAMCs even though it has moved forward with planning the national 
rollout of Phase II in operating room, emergency department, and 
spinal cord injury units. ONS, however, has assessed some of the 
available resources of the sites that have participated in the pilots 
for Phase II in spinal cord injury units. For example, ONS officials 
told us that they asked these participating sites questions about 
their access to data and nurse turnover within the pilot units to 
determine their ability to fully and successfully participate in the 
pilot. According to ONS officials, all sites reported that they were 
able to fully participate in the pilot. By not comprehensively 
assessing the VAMCs' technical support and resources to determine if 
they were prepared to implement the methodology, VHA had no assurance 
that the VAMCs would be successful. 

Plan for Monitoring Compliance. ONS did not develop a plan for 
monitoring VAMCs to ensure they were in compliance with the 
implementation and ongoing administration of Phase I of the 
methodology. Under federal internal control standards, plans should be 
designed to ensure that ongoing monitoring occurs in the course of 
normal program operations, and managers should identify performance 
gaps in compliance with program policies and procedures. 

ONS reported implementing two mechanisms for obtaining information 
from VAMCs—-a 2013 questionnaire sent to all VAMCs and monthly 
methodology conference calls with VAMCs-—but neither was an adequate 
mechanism for comprehensively assessing the compliance of each VAMC. 
The questionnaire, sent nearly 2 years after the deadline for 
implementation of Phase I of the methodology, asked VAMCs to report 
their status of staffing plan development, but because of lack of 
clarity in the questions asked, inconsistency in medical center 
responses, and lack of validation of the self-reported responses, it 
was not reliable for determining the extent to which VAMCs had 
developed staffing plans. ONS officials reported that they have no 
plans to survey VAMCs again on their status of developing staffing 
plans. Furthermore, the monthly methodology conference calls that 
started when the directive was published in 2010 did not provide an 
adequate mechanism for monitoring compliance because they too relied 
on VAMCs to self-report problems. A VAMC official told us that 
participants were reluctant to raise problems, such as not developing 
staffing plans on time, during these monthly calls. 

In addition, the directive requires VAMCs to evaluate their staffing 
plans for Phase I annually, or more frequently if needed, but ONS 
officials told us that they did not have a systematic plan for 
monitoring compliance with this evaluation beyond the 2013 
questionnaire and the monthly methodology conference calls. Moving 
forward, ONS officials said they plan to review whether all VAMCs 
implemented both the unit and facility expert panels, but, as of 
August 2014, had no detailed plan or timeline for conducting this 
review or for monitoring VAMCs' ongoing evaluation of their staffing 
plans. The lack of a plan for monitoring VAMCs' compliance with the 
implementation and ongoing administration of the methodology hinders 
VHA from being able to ensure that all VAMCs are staffing their nurses 
using the same, standardized methodology. 

Evaluation. There have been limited evaluations of the methodology, 
and one of these evaluations has been significantly delayed. Under 
federal internal control standards, measuring performance allows 
organizations to track the progress they are making towards program 
goals and objectives, and provides managers important information on 
which to make management decisions and resolve any problems or program 
weaknesses. 

* Evaluation of Phase I pilot (conducted in September 2009)—ONS 
identified VAMC challenges with implementing the methodology—such as 
difficulties accessing data, and staff nurses having an overall lack 
of knowledge of the methodology process. The evaluation contained 
recommendations, such as developing a training guidebook and providing 
guidelines on the role of the expert panels, to improve the 
methodology process. According to ONS, most of the recommendations 
from this 2009 evaluation have been addressed; however, we found that 
weaknesses identified in the 2009 evaluation still existed for all of 
the seven VAMCs included in our review. 

* Evaluations of Phase I national implementation and training (began 
early 2014, preliminary results were expected August 2014). Similarly, 
ONS did not begin an evaluation of the national implementation of the 
methodology until January 2014, more than 2 years after VAMCs were 
required to have implemented it, and, as of August 2014, had still not 
been completed. According to ONS officials, the Phase I national 
evaluation was to review VAMCs' experiences during implementation, 
including a review of the training provided to VAMCs during that 
phase. The lengthy delay in the evaluation of Phase I was potentially 
problematic because the ongoing difficulties that VAMCs have 
experienced during implementation may have been avoided or resolved 
more quickly if the evaluation results had been available and 
corrective actions put into place. VAMC staff we interviewed told us 
they have been struggling with components of the methodology since the 
directive was issued. For example, some VAMC staff expressed 
difficulty completing and understanding the data analysis process for 
calculating NHPPD. An earlier evaluation of the methodology could have 
helped identify this problem, as well as potential solutions to 
address it. Furthermore, the delay limited ONS's time to apply lessons 
learned from Phase I evaluations to the implementation of Phase II, 
portions of which are already nearly complete. 

* Phase II pilot training evaluation (began in early 2014 with results 
expected November 2014)—ONS is conducting an evaluation of the 
training that was provided to the VAMCs involved in the Phase II 
pilots in operating room, emergency department, and spinal cord injury 
units to determine if the training provided to these units needs to be 
changed in preparation for the national rollout. ONS officials told us 
that they have completed the operating room pilot; the national 
rollout of the methodology in operating room units in all VAMCs began 
in February 2014 and is expected to be completed by October 1, 2014. 
ONS officials said that it has completed the pilot for the emergency 
department units, but has not completed the pilot for spinal cord 
injury units; ONS has not scheduled deadlines for their national 
implementation. 

VHA's delays in completing evaluations of the methodology limit its 
ability to identify and resolve VAMC implementation and administration 
problems, and thus help to ensure successful rollouts of subsequent 
phases of the methodology. 

Timeliness of Implementation and Communication. The long timeline for 
implementing the pilots and national rollouts of Phases I and II, as 
well as evaluating Phase I of the staffing methodology—more than 7 
years—and for communicating methodology-related information to VAMCs 
may have hindered the ability of VAMCs to develop their staffing plans 
and to execute the initiatives contained in those plans. Under federal 
internal control standards, timeliness in the development of a program 
or implementation of a policy is needed to maintain relevance and 
value in managing operations and making decisions. When information 
regarding a policy or program is not provided in a timely manner, 
there can be a loss of stakeholder support, which can affect how 
stakeholders make decisions. For example, staff from some VAMCs 
involved in the Phase II pilot stated that they believed the data and 
reports generated from the methodology were only a paper exercise 
because they had not gotten any feedback from ONS on next steps. ONS 
officials told us they have communicated information on the Phase II 
pilot, such as the status of the pilot and feedback obtained from the 
training sessions, through their monthly conference calls with VAMCs; 
however, based on our interviews, this information did not reach many 
staff at the VAMCs in our review that participated in the Phase II 
pilot. 

Furthermore, ONS officials have not adequately communicated to VAMCs 
the status of Phase III of the methodology—development of a national 
automated staffing system. According to the directive, a national 
automated staffing system was to be developed to support VAMCs in the 
implementation of the methodology. Because this automated staffing 
system has yet to be developed as per the directive, officials from 
two VAMCs told us they bought their own systems, which helped to 
effectively administer the methodology. ONS officials told us at the 
time the directive was published in 2010, Phase III implementation was 
an aspirational goal. ONS officials said they had expected VHA data 
system teams to begin the process of developing a national automated 
system; however, it was not made a department goal, and is not 
currently on the list of projects under consideration for funding. 
Having a variety of staffing systems, and thus inconsistent data 
variables across VAMCs, inhibits ONS's ability to adequately evaluate 
the effectiveness of the staffing methodology. If an automated 
staffing system is eventually developed under Phase III, VAMCs likely 
will have to dismantle the staffing systems they have created and 
restructure their data analysis processes, which likely will be time-
consuming and costly. VHA's long timelines for the implementation and 
communication of methodology-related information put stakeholder 
support of the methodology at risk and increase the potential for 
duplication of efforts. 

Organizational Accountability. VHA did not define areas of 
responsibility or establish the appropriate line of reporting within 
the framework of VA's management structure for the ongoing 
administration and oversight of the methodology. Under federal 
internal control standards, an agency's organizational structure 
should provide management with a framework for planning, directing, 
and controlling operations to achieve agency objectives; a good 
internal control environment requires that the agency clearly defines 
key areas of authority and responsibility. VHA does not require VAMCs 
to submit any information or reports on the implementation and ongoing 
administration of the methodology to ONS or the VISNs. Such 
information, if it were shared, may have been used to inform ONS of 
any systematic problems that necessitate changes to help ensure the 
continued viability of its methodology, as well as identify any best 
practices that have been implemented by VAMCs across the country. ONS 
officials told us that they did not require the VAMCs to submit any 
such documentation to ONS, because they made a conscious decision to 
not “micro-manage” the local process of nurse staffing. 

Furthermore, VHA has not sufficiently utilized the VISN-level 
management structure in the implementation or ongoing administration 
of the methodology. While the methodology directive described a role 
for the VISNs, that role was limited to ensuring that resources are 
available to VAMCs as they try to staff their units; the directive did 
not mention a role in the implementation or ongoing administration of 
the actual methodology. As a result, VISNs have not been consistently 
aware of problems experienced by VAMCs in their region, and have not 
provided support or education. In our interviews with VISN officials 
representing each of the seven VAMCs in our review, we found that 
three of the VISNs were not substantively involved in the 
implementation and ongoing administration of the methodology. 
According to ONS, in many VISNs, discussions of staffing methodology 
implementation were minimal, and rather than VISN leadership, the 
nurse executives, in addition to their responsibilities within their 
individual VAMCs, had the responsibility of disseminating staffing 
methodology-related information to the VAMCs within the VISN. 

Staff from three VISNs that were more substantially involved in the 
implementation of the methodology provided oversight for the nurse 
staffing methodology and acted as liaisons for VAMC nurse executives 
for network-level issues. One VISN official we interviewed was 
developing oversight mechanisms for VAMCs in the region, including a 
requirement for nurse executives to submit a quarterly staffing 
report. According to the official, having such a reporting requirement 
at the VISN level would give the right amount of emphasis to the 
process and provide support to nurse executives implementing the 
methodology in the VAMCs. The quarterly report could also help inform 
VISN officials about issues with the methodology. This official was 
developing these mechanisms independently of ONS, but they could be 
considered potential best practices to be shared across all VISNs ONS 
officials told us they thought ideas or problems across VAMCs related 
to the methodology would be shared through the VAMC nurse executives. 
They also hoped that VISN leadership would be interested in the 
methodology and, as a result, schedule VISN-level briefings to aid in 
its implementation. VHA, however, did not specify either of these 
roles in the directive or take steps to ensure that they were 
occurring. Moving forward, ONS officials said they are considering 
developing a VISN-level staff position that would specifically focus 
on educating VAMCs within the region about the methodology, and 
assisting them with implementing it. Without clearly defined roles and 
responsibilities within VA's organizational structure, VHA's ability 
to improve its oversight of the implementation and administration of 
the staffing methodology and provide VAMCs with additional resources 
to assist with problems is compromised. 

Conclusions: 

As the number of veterans requiring care in VAMCs and the complexity 
of services needed by many of these veterans increase, the need for an 
adequate and qualified nurse workforce is increasingly critical. 
Although VHA's nurse staffing methodology was intended to provide a 
nationally standardized methodology for determining and ensuring 
adequate and qualified nurse staffing at VAMCs, its ability to do so 
across all 151 VAMCs is not likely to be realized unless existing 
weaknesses are addressed. Although some improvements in nurse staffing 
were reported with the implementation of the staffing methodology, the 
seven VAMCs in our review experienced problems developing and 
executing the related staffing plans, including problems pertaining to 
data resources, training, and communication. Many of these problems 
persist as the seven VAMCs continue to administer the methodology. 

We also found that VHA's oversight of the staffing methodology is 
limited and in many cases lacks sufficient internal controls, which 
could diminish VHA's ability to ensure an adequate and qualified nurse 
workforce. In particular, VHA has not adequately assessed the needs or 
preparedness of VAMCs to effectively implement the methodology, does 
not have a formal mechanism to ensure VAMCs' ongoing compliance with 
the methodology, has not clearly defined a role in oversight for 
VISNs, and does not regularly communicate with VAMCs or VISNs to cull 
and share best practices system-wide. Furthermore, delays in VHA's 
evaluations of early phases of the staffing methodology have made them 
too late to be useful in designing future phases or helping VAMCs with 
implementation. Because the implementation and administration of the 
nurse staffing methodology is ongoing, it is critical that VHA improve 
its oversight to help ensure an adequate and qualified nurse workforce 
across all VAMCs. 

Recommendations for Executive Action: 

To help ensure adequate and qualified nurse staffing at VAMCs, we 
recommend that the Secretary of Veterans Affairs direct the Interim 
Under Secretary for Health to enhance VHA's internal controls through 
the following five actions: 

1. Provide support to all VAMCs to meet the objectives of the VHA 
directive, including: 
a. training that more clearly aligns with the needs of VAMC staff and
b. a systematic process for collecting and disseminating staffing 
methodology best practices; 

2. Conduct an environmental assessment of all VAMCs, including an 
assessment of their data analysis needs, to determine their 
preparedness to implement the remaining phases of the methodology, and 
use that information to help guide and provide the necessary support 
for the implementation of the remaining phases and for the ongoing 
administration of the methodology; 

3. Develop and implement a documented process to assess VAMCs' ongoing 
compliance with the staffing methodology, including assessing VAMCs' 
execution of staffing plans and more clearly defining the role and 
responsibilities of all organizational components, including VISNs, in 
the oversight and administration of the methodology; 

4. Complete evaluations of Phase I and Phase II and make any necessary 
changes to policies and procedures before national implementation of 
Phase II in all VAMCs; and; 

5. Improve the timeliness and regularity of communication with VAMCs, 
including unit-level staff, regarding the status of the various phases 
of the methodology. 

Agency Comments: 

We provided a draft of this report to VA for its review and comment. 
VA provided written comments, which are reprinted in appendix I. In 
its written comments, VA generally agreed with our conclusions and 
concurred with all five of the report's recommendations. To address 
the recommendations, VA indicated that VHA will take a number of 
actions, such as developing a written document specifying its process 
for assessing ongoing compliance with the staffing methodology and 
improving the timeliness and regularity of communication with VAMCs 
through face-to-face regional training sessions. VA indicated that 
target completion dates for implementing these recommendations range 
from September 2015 through September 2016. Regarding the 
recommendation that VA complete evaluations of Phase I and Phase II 
before national implementation of Phase II in all VAMCs, VA indicated 
that, by September 2016, it would complete its evaluations and 
determine what opportunities exist to modify policies and procedures, 
but did not explicitly state that the evaluations would be completed 
before national implementation. We continue to emphasize the 
importance of completing the evaluations before national 
implementation of Phase II in all VAMCs. 

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies of this report 
to appropriate congressional committees, the Secretary of Veterans 
Affairs, and other interested parties. In addition, the report will be 
available at no charge on the GAO Web site at [hyperlink, 
http://www.gao.gov. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or draperd@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix II. 

Sincerely yours, 

Signed by: 

Debra A. Draper: 
Director, Health Care: 

[End of section] 

Appendix I: Comments from the Department of Veterans Affairs: 

Subsequent to receiving VA's letter, the report number, GAO-14-838, 
was revised to GAO-15-61. 

Department Of Veterans Affairs: 
Washington, DC 20420: 

September 29, 2014: 

Ms. Debra Draper: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Draper: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, "VA HEALTH CARE: Actions 
Needed to Ensure Adequate and Qualified Nurse Staffing" (GAO-14-838). 
VA generally agrees with GAO's conclusions and concurs with GAO's 
recommendations to the Department. 

The enclosure specifically addresses GAO's recommendations and 
provides an action plan for each. VA appreciates the opportunity to 
comment on your draft report. 

Sincerely, 

Signed by: 

Jose D. Riojas: 
Chief of Staff: 

Enclosure: 

Department of Veterans Affairs (VA) Response to Government 
Accountability Office (GAO) Draft Report "VA HEALTH CARE: Actions 
Needed to Ensure Adequate and Qualified Nurse Staffing" (GAO-14-838): 

GAO Recommendation: To help ensure adequate and qualified nurse 
staffing at VAMCs, GAO recommends that the Secretary of Veterans 
Affairs direct the Interim Under Secretary for Health to enhance VHA's 
internal controls through the following five actions: 

Recommendation 1: Provide support to all VAMCs to meet the objectives 
of the VHA directive, including: 
a. training that more clearly aligns with the needs of VAMC staff and; 
b. a systematic process for collecting and disseminating staffing 
methodology best practices; 

VA Comment: Concur. In fiscal year (FY) 2014, the Office of Nursing 
Services (ONS) identified the need to enhance support to all 
Department of Veterans Affairs (VA) medical centers (VAMC) to meet the 
objectives in the Veterans Health Administration (VHA) Directive 2010-
034, Staffing Methodology for VHA Nursing Personnel. ONS is VHA's 
staff proponent for execution of the nurse staffing methodology. 

One aspect of the enhanced support was the need to evaluate the 
training associated with staffing methodology implementation to ensure 
it more clearly aligns with the needs of VAMC staff. An external 
evaluation team was selected to assess the training conducted for the 
staffing methodology. Results from the evaluation of field staff . 
expertise will inform follow-on training. 

To develop the infrastructure to support staffing methodology, ONS 
will use a model that has been successful for the Nursing Professional 
Standards Board (NPSB) training. Similar to NPSB, the staffing 
methodology regional consultants will be trained to perform 
standardized staffing methodology consultations. Beginning FY 2015, 
the regional consultant program will be developed, and regional 
consultants will be identified. A face-to-face meeting will take place 
the 3rd quarter of FY 2015 to provide regional consultant training. 

ONS has a Staffing Methodology Steering Committee (SMSC) that has been 
in place since 2007. The SMSC provides advice and guidance to ONS 
regarding staffing methodology implementation in the field. Since 
2010, ONS in collaboration with the SMSC, has facilitated a monthly 
National Staffing Methodology Call (NSMC) with facility staffing 
methodology representatives. They have also created a staffing 
methodology coordinators email distribution group. 

The NSMC and the staffing methodology coordinators email distribution 
group will be used to solicit best practices from the field. 
Additionally, input from the field will be requested, which will 
inform Frequently Asked Questions (FAQs). Field input on best 
practices and FAQs will be submitted to the SMSC for consideration and 
development of national responses. Approved content will be 
disseminated back to the field. FAQs and approved responses will be 
posted on the established ONS staffing methodology Web page. This 
input will be used to inform policy and procedure modifications, if
necessary. Target Completion Date: September 2015. 

Recommendation 2: Conduct an environmental assessment of all VAMCs, 
including an assessment of their data analysis needs, to determine 
their preparedness to implement the remaining phases of the 
methodology, and use that information to help guide and provide the 
necessary support for the implementation of the remaining phases and 
for the ongoing administration of the methodology; 

VA Comment: Concur. Sources of Nursing Hours Per Patient Day (NHPPD) 
comparison data for setting target NHPPD will be explored. VAMCs will 
be provided with Annual Nursing Survey Reports. The reports list 
comparison data relevant to a specific unit type. The data are 
necessary to develop a baseline approach to linking NHPPD. 

ONS acknowledges VHA's need to conduct a formal external evaluation on 
the current implementation of the staffing methodology Directive. The 
evaluation is underway, and VHA expects it will be completed during 
the first quarter of FY 2015. The evaluation collects facility-level 
quantitative and qualitative data through focused interviews with 
facility representatives and all VAMC Nurse Executives. The survey 
results will provide ONS with data on preparedness and recommendations 
related to implementation of the remaining phases of the nurse 
staffing methodology. ONS will use data from the evaluation to develop 
guidance that best supports the field during implementation of the 
staffing methodology going forward. 

An additional survey focused on training effectiveness is also 
underway. This evaluation will provide data that will enhance the 
current training techniques provided to the field. Both evaluations 
will provide ONS information to help guide and provide the necessary 
support for the implementation and for the ongoing administration of 
the staffing methodology. Target Completion Date: September 2015. 

Recommendation 3: Develop and implement a documented process to assess 
VAMCs' ongoing compliance with the staffing methodology, including 
assessing VAMCs' execution of staffing plans, and more clearly 
defining the role and responsibilities of all organizational 
components, including VISNs, in the oversight and administration of 
the methodology; 

VA Comment: Concur. ONS will develop a written document that specifies 
the VHA's process for assessing ongoing compliance with the staffing 
methodology at the facility level. This written process will include 
how each facility assesses execution of staffing plans and clear 
definitions of the roles and responsibilities in the oversight and
administration of the staffing methodology for all organizational 
components (i.e., ONS, Veterans Integrated Service Network, facility, 
service line). 

Implementation of the process will include on-site, in-depth 
consultations, consistent with those that have been underway during FY 
2014. The consultations are conducted with members of unit-based and 
facility-based expert panels. 

In addition, a staffing methodology implementation checklist will be 
developed which facilities will use as a measurement of full staffing 
methodology Directive compliance. The checklist will serve as a 
staffing methodology self-assessment, which will be distributed to the 
field in collaboration with the Office of the Deputy Under Secretary 
for Health for Operations and Management. Lastly, a consultation 
session (virtual or on-site) will be conducted with all non-compliant 
sites. The combined checklist, self-assessment, and consultation will 
assess facility compliance with the staffing methodology. Target 
Completion Date: September 2016. 

Recommendation 4: Complete evaluations of Phase I and Phase II, and 
make any necessary changes to policies and procedures before national 
implementation of Phase II in all VAMCs; and; 

VA Comment: Concur. ONS will complete evaluations of Phase I and Phase 
II to assess the existing staffing methodology initiative and current 
staffing methodology policies and procedures for possible 
opportunities for improvement. The evaluation will include current 
approaches to training and will provide recommendations to optimize 
training for remaining Phase I and Phase II rollouts. 

Once the evaluation is completed, the results shall be analyzed to 
determine what opportunities exist, if any, to modify policies and 
procedures. Target Completion Date: September 2016. 

Recommendation 5: Improve the timeliness and regularity of 
communication with VAMCs, including unit-level staff, regarding the 
status of the various phases of the methodology. 

VA Comment: Concur. ONS has already established a monthly National 
Staffing Methodology Call (NSMC) and staffing methodology coordinators 
email distribution group available to all VHA employees who desire to 
be on the call and distribution group. ONS will continue to utilize 
the NSMC distribution group for field-level communication. 

Timeliness and regularity of communication will be improved by 
utilizing face-to-face Regional Staffing Methodology Training Sessions 
(RSMTS), the ONS intranet Web site, the staffing methodology 
coordinators email distribution group, and the ONS Bulletin.
A request to conduct four RSMTS during FY 2015 was made through the 
Employee Education System. The training will provide staffing 
methodology training to roughly 80-90 attendees at each session. In 
addition, it will provide facilities an opportunity to send a facility 
staffing methodology representative to learn the staffing methodology 
in a classroom setting. This training is pending VI-IA approval. 

A timeline section will be developed on the ONS staffing methodology 
Web page. The timeline will provide the status of all phases of 
national implementation. This will include all areas that have been 
implemented, the implementation dates of all pilot roll-outs, status 
of all current pilots, and possible future pilots. 

Regular status updates will be provided to the staffing methodology 
coordinators email distribution group on a monthly basis and on the 
monthly NSMC agenda. 

Status updates will be included in the monthly ONS Bulletin. Target 
Completion Date: September 2015, 

[End of section] 

Appendix II: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Debra A. Draper, (202) 512-7114 or draperd@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Janina Austin, Assistant 
Director; Jennie Apter; Kathryn Black; Jacquelyn Hamilton; Kelli 
Jones; Vikki L. Porter; and Karin Wallestad made key contributions to 
this report. 

[End of section] 

Footnotes: 

[1] See, for example, R.L. Kane et al., Nurse Staffing and Quality of 
Patient Care, Pub. No. 07-E005, March 2007, Agency for Healthcare 
Research and Quality; and Kaiser Permanente Institute for Health 
Policy, Nurse Staffing and Care Delivery Models: A Review of the 
Evidence (Menlo Park, Calif.: March 2002). 

[2] Pub. L. No. 107-135, Title I, § 124, 115 Stat. 2446, 2452 (Jan. 
23, 2002). 

[3] See Department of Veterans Affairs, Office of the Inspector 
General, Healthcare Inspection: Evaluation of Nurse Staffing in 
Veterans Health Administration Facilities, 03-00079-183 (Washington, 
D.C.: Aug. 13, 2004). 

[4] See GAO, VA Health Care: Improved Staffing Methods and Greater 
Availability of Alternate and Flexible Work Schedules Could Enhance 
the Recruitment and Retention of Inpatient Nurses, [hyperlink, 
http://www.gao.gov/products/GAO-09-17] (Washington, D.C.: Oct. 24, 
2008). 

[5] VA assigns each VAMC a complexity score derived from multiple 
variables to measure facility complexity arrayed along four 
categories, namely: patient population served, clinical services 
offered, education and research complexity, and administrative 
complexity. 

[6] Magnet status is a designation of the Magnet Recognition Program®-
-a nationwide program developed by the American Nurses Credentialing 
Center, a subsidiary of the American Nurses Association, to recognize 
health care organizations for quality patient care, nursing 
excellence, and innovations in professional nursing practice. To 
attain Magnet status, hospitals must meet certain requirements, 
related to areas including staffing practices and quality monitoring. 

[7] We spoke with officials from the Disabled American Veterans and 
Paralyzed Veterans of America who are knowledgeable about nurse 
staffing methodologies in VAMC inpatient units, such as spinal cord 
injury units. 

[8] We interviewed officials from the American Nurses Association. We 
also contacted each of the nursing organizations that VHA officials 
told us work with VA nurses: American Federation of Government 
Employees, National Nurses United, National Association of Government 
Employees, National Federation of Federal Employees, and Nurses 
Organization of Veterans Affairs. 

[9] Each of VA's 21 VISNs is responsible for managing and overseeing 
VAMCs within a defined geographic area. 

[10] GAO, Managing For Results: GPRA Modernization Act Implementation 
Provides Important Opportunities to Address Government Challenges, 
[hyperlink, http://www.gao.gov/products/GAO-11-617T] (Washington, 
D.C.: May 10, 2011); Executive Guide: Effectively Implementing the 
Government Performance and Results Act, [hyperlink, 
http://www.gao.gov/products/GAO/GGD-96-118] (Washington, D.C.: June 
1996); Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] 
(Washington, D.C.: November 1999); Internal Control Management and 
Evaluation Tool, [hyperlink, http://www.gao.gov/products/GAO-01-1008G] 
(Washington, D.C.: August 2001); VA Dialysis Pilot: Increased 
Attention to Planning, Implementation, and Performance Measurement 
Needed to Help Achieve Goals, [hyperlink, 
http://www.gao.gov/products/GAO-12-584] (Washington, D.C.: May 23, 
2012); Managing For Results: Executive Branch Should More Fully 
Implement the GPRA Modernization Act to Address Pressing Governance 
Challenges, [hyperlink, http://www.gao.gov/products/GAO-13-518] 
(Washington, D.C.: June 26, 2013). 

[11] According to VHA, the workforce data for RNs also include RNs 
with advanced degrees such as nurse practitioners. 

[12] LPNs and licensed vocational nurses have the same level of 
education and patient care responsibilities. For the purposes of this 
report, when we refer to LPNs, we are referring to both LPNs and 
licensed vocational nurses. 

[13] VHA also employs nurses to work outside VAMCs, such as those 
employed within its administrative offices. These nurses were not 
included in our review. 

[14] See Department of Veterans Affairs, Veterans Health 
Administration, 2013 Workforce Succession Strategic Plan (Washington, 
D.C.: 2013). 

[15] VHA's directive defines direct patient care as all patient-or 
resident-centered nursing activities performed by staff assigned to 
the unit. These activities include nursing assessments, admission and 
discharge activities, and patient teaching and communication. 

[16] J. Spetz et al., "How Many Nurses Per Patient?" Health Services 
Research, vol. 43 (October 2008): 1674-1692; Carayon, P. and A. 
Gurses, "Nursing Workload and Patient Safety in Intensive Care Units: 
A Human Factors Engineering Evaluation of the Literature," Intensive 
and Critical Care Nursing, vol. 21 (2005): 284-301; and American 
Association of Critical-Care Nurses, Standards for Establishing and 
Sustaining Healthy Work Environments (Aliso Viejo, Calif.: American 
Association of Critical-Care Nurses, 2005). 

[17] According to ONS officials, the staffing methodology for these 
units were to be implemented separately from those included in Phase I 
because of the potential need to modify the methodology to align with 
the special services these units provide. 

[18] See Department of Veterans Affairs, Office of the Inspector 
General, Combined Assessment Program Summary Report: Evaluation of 
Nurse Staffing in Veterans Health Administration Facilities April - 
September 2013, Report No. 14-01072-140 (Washington, D.C.: May 12, 
2014). 

[19] See Department of Veterans Affairs, Office of the Inspector 
General, Combined Assessment Program Summary Report: Evaluation of 
Nurse Staffing in Veterans Health Administration Facilities, Report 
No. 13-01744-187 (Washington, D.C.: April 30, 2013). 

[20] Joint Commission on Accreditation of Healthcare Organizations, 
Health Care at the Crossroads: Strategies for Addressing the Evolving 
Nursing Crisis (Chicago, Ill.: Joint Commission on Accreditation of 
Healthcare Organizations, 2002). 

[21] See American Nurses Association, Principles for Nurse Staffing, 
Second Edition (Silver Spring, Md.: American Nurses Association, 2012). 

[22] Institute of Medicine, The Future of Nursing: Leading Change, 
Advancing Health (Washington, D.C.: The National Academies Press, 
2011). 

[23] See R.L. Kane et al., Nurse Staffing and Quality of Patient Care, 
Pub. No. 07-E005, March 2007, Agency for Healthcare Research and 
Quality; and "Hospital Nurse Staffing and Quality of Care," Agency for 
Healthcare Research and Quality, Research in Action, Issue 14, Pub. 
No. 04-0029 (Rockville, Md.: 2004). 

[24] M.A. Blegen et al., "Nurse Staffing Effects on Patient Outcomes: 
Safety-Net and Non-Safety-Net Hospitals," Medical Care, vol. 49, issue 
2 (April 2011), 406-414; J. Needleman et al., "Nurse Staffing and 
Inpatient Hospital Mortality," New England Journal of Medicine, vol. 
364, issue 11 (March 2011), 1037-1045; L.H. Aiken et al., 
"Implications of the California Nurse Staffing Mandate for Other 
States," Health Services Research, vol. 45, issue 4 (April 2010), 904-
921; and P.W. Stone et al., "Nurse Working Conditions and Patient 
Safety Outcomes," Medical Care, vol. 45, issue 6 (June 2007), 571-578. 

[25] A.P. Bartel et al., "Human Capital and Productivity in a Team 
Environment: Evidence from the Healthcare Sector," American Economic 
Journal: Applied Economics, vol. 6, issue 2 (2014), 231-259. 

[26] A. Kutney-Lee, D.M. Sloane, and L.H. Aiken, "An Increase In The 
Number Of Nurses with Baccalaureate Degrees Is Linked To Lower Rates 
Of Postsurgery Mortality," Health Affairs, vol. 32, issue. 3 (March 
2013), 579-586; L.H. Aiken et al., "Effects of Hospital Care 
Environment on Patient Mortality and Nurse Outcomes," Journal of 
Nursing Administration, vol. 38, issue 5 (May 2008), 223-229; and C.R. 
Friese et al., "Hospital Nurse Practice Environments and Outcomes for 
Surgical Oncology Patients," Health Services Research, vol. 43, issue 
4 (August 2008), 1145-1163. 

[27] J. Spetz, "Nurse Satisfaction and the Implementation of Minimum 
Nurse Staffing Regulations," Policy, Politics, & Nursing Practice, 
vol. 9 (Feb. 2008, first published on April 3, 2008), 15-21; and L.H. 
Aiken et al., "Hospital Nurse Staffing and Patient Mortality, Nurse 
Burnout, and Job Dissatisfaction," The Journal of the American Medical 
Association, vol. 288, issue 16 (October 2002), 1987-1993. 

[28] A.W. Stimpfel, D.M. Sloane, and L.H. Aiken, "The Longer the 
Shifts for Hospital Nurses, the Higher the Levels of Burnout and 
Patient Dissatisfaction," Health Affairs, vol. 31, issue 11 (November 
2012), 2501-2509; J.P. Cimiotti et al., "Nurse Staffing, Burnout, and 
Health Care-Associated Infection," American Journal of Infection 
Control, vol. 40 (August 2012) 486-490; and D.C. Vahey et al., "Nurse 
Burnout and Patient Satisfaction," Medical Care, vol. 42, issue 2 
(Feb. 2004), 57-66. 

[29] Fixed nurse-to-patient ratios assign a certain number of patients 
to each nurse (e.g., one nurse for every five patients) while 
adjustable, unit-specific, minimum staffing levels assign minimum 
ratios of nurses to patients for each unit and shift that reflects the 
needs of the patient population and matches the skills and experience 
of the staff. 

[30] These are illustrative examples of different approaches; we did 
not conduct a comprehensive review of all state requirements. 

[31] As previously described, VAMCs were required to implement the 
methodology in inpatient units (Phase I) no later than September 30, 
2011. VAMCs were expected to implement the methodology in their 
operating rooms by October 1, 2014; requirements for implementation of 
Phase II in other units and Phase III of the methodology have not been 
set. 

[32] Transport teams are staff who assist in transporting patients to 
and from appointments off the unit. Sitters are staff who provide one-
on-one direct patient observation. 

[33] NDNQI was created as part of the American Nurses Association's 
Patient Safety and Quality Initiative to identify the linkages between 
staffing and patient outcomes. The database contains data on quality 
indicators and staff levels collected from approximately 2,000 
hospitals that submit data on nursing-sensitive indicators, such as 
pressure ulcers and patient falls. According to the American Nurses 
Association, 98 percent of all Magnet facilities use some aspect of 
NDNQI data. 

[34] According to the staffing methodology directive, a comparative 
analysis of NHPPD data from other resources is also recommended, such 
as from the Labor Management Institute and NDNQI. Labor Management 
Institute data compare direct, indirect, and total worked hours of 
care by hospital and unit type, and NDNQI data contain information on 
quality indicators and staff levels. 

[End of section] 

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