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The Need for a Staffing Methodology for the Veterans Health Administration
The prediction of staffing requirements for enterprises is part of the essential structure of any business or agency. Too low a staffing level directly impacts the ability of the enterprise to function effectively, while too high a level consumes excess resources. Beyond the overall staffing level of the enterprise is the issue of how to allocate staff to the whole set of tasks that must be performed, so as to minimize local staffing shortages or overages of specific staff expertise. Where the enterprise staffing consists of repetitive tasks, there have long been methods of determining the numbers and distribution of staff to meet projected output demands. In contrast, as more tasks involve nonrepetitive work, such methods become problematical, so that other techniques must be used to derive valid predictions of staffing needs. These methods have become known collectively as “staffing models.”
The Veterans Health Administration (VHA) requested that the National Academies of Sciences, Engineering, and Medicine “prepare a comprehensive resource planning and staffing methodology guidebook for VHA Facility Management (Engineering) Programs” by reviewing the tasks of VHA building facilities staff and recommending actions for VHA to meet the mission goals of delivering patient care, research, and effective operations. VHA needed such a methodology in part to guide its own staffing decisions and in part to comply with current congressional mandates. The National Academies has performed similar developments for other agencies and so has considerable knowledge of how staffing models are developed and used. At least one of these projects for another agency (the Federal Aviation Administration [FAA]) specifically addressed models of facilities maintenance activities (NRC, 2013). These earlier projects developed literature on staffing models and their development so that the current project could begin at a relatively high level of current knowledge.
The Department of Veterans Affairs (VA) is one of the largest federal property-holding agencies, with more than 33,000 acres of land, more than 5,500 buildings, and almost 153 million gross square feet. The VA uses this diverse inventory of real property to provide health care and other services to millions of veterans. In order to provide accessible, high-quality, and cost-effective access to services, the VA contracts and has in-house personnel for a building facilities workforce to plan, design, construct, commission, operate and maintain, repair, recapitalize, and dispose of these facilities. Facilities specific to the VHA division fulfill clinical, operational (i.e., physical plants), research laboratory, and administrative functions. VHA is, according to its website, “America’s largest integrated health care system, providing care at 1,243 health care facilities, including 172 medical centers and 1,063 outpatient sites of care of varying complexity, serving 9 million enrolled veterans each year.”1 As many of these
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1 As of April 2019.
facilities age, VHA is faced with the growing challenge of maintaining them at a level that enables health-care workers to meet veterans’ needs. While the construction of new facilities supports this task, it is also the case that many older buildings have developed modularly over time—for example, a 1920s-era hospital may have had an addition in 1950, which in turn got an addition in 1970, and yet another addition in 1990, and so on. The task of caring for these old buildings, some of which are historically or architecturally significant, at a level that supports contemporary health-care standards of practices, is substantial. At the same time, maintaining the finely tuned workings of new, more technologically advanced facilities also demands considerable expertise and commitment.
STUDY ORIGIN
Facilities issues arise throughout VHA’s diverse inventory and at all sites—clinical, research, operational, and administrative offices alike. Challenges arise in both new and old facilities, although the types of concerns may differ. For example, even a brand-new building may have problems with inadequate air circulation, which can lead to indoor air-quality problems unless remedied. Older buildings, on the other hand, more frequently face age-related issues such as inefficient energy systems that can lead to uncomfortable indoor climate and high utility bills. While extreme environmental conditions and a lack of maintenance funding contribute to building deterioration, many facilities problems are related to maintenance staffing levels, training, and management practices.
A 2004 comprehensive review of the VA’s Capital Asset Realignment for Enhanced Services (CARES) facility condition assessments and other relevant information revealed a need to prospectively reconsider the qualifications of managers of Health Care Facilities Engineering Programs (GPO, 2004). In consideration of the highly complex technical nature of today’s health-care facilities, the overall age of the infrastructure in which VHA delivers care, and the available infrastructure-related resources, increased professional surveillance and technical management are prudent measures to help prevent untoward and potentially catastrophic events.
Because routine and unexpected maintenance demands are bound to arise, every facility organization should proactively develop and implement an objective staffing plan aligned with operational requirements to meet the challenges of effective facilities maintenance. It is irrational to address these in a haphazard fashion, particularly in health-care institutions, considering that the consequences affect patient delivery, patient and staff health, day-to-day building operations, and the long-range fiscal outlook of the organization.
Sound facilities’ staffing plans help ensure that facilities are, and will be, cared for appropriately. On the other hand, negligent facilities staffing can cause real problems. Large capital investment can be squandered when buildings and equipment deteriorate or warranties become invalidated. Failing to maintain facilities adequately also discourages future investment in the veterans’ health delivery system.
Facilities staffing plans serve as strategic determinations of operational requirements to be shared with everyone in the institution. They are the result of a process that requires participants from all levels of an organization working together to decide on fair and equitable workloads while ensuring good service to customers. Although the numbers generated by a staffing model justify and quantify, they are no substitute for a comprehensive staffing plan.
CHARGE TO THE COMMITTEE
Recognizing these issues, VHA requested that the National Academies review the work performed by the VHA Facility Management (Engineering) Programs and recommend actions for VHA to meet the mission goals of delivering patient care, research, and effective operations through a national VHA engineering resourcing and staffing methodology. The full statement of task for the Committee on Facilities Staffing Requirements for Veterans Health Administration is in Box 1.1.
COMMITTEE APPROACH
To achieve the goals of the project, it was necessary to structure an appropriate committee, collect data and reports on the scope and complexity of the VHA’s Facility Management (Engineering) tasks, review currently accepted staffing models applicable to facilities activities, and finally develop conclusions, findings, and
recommendations in a manner that responded to the statement of task. To perform this task, the National Academies formed a committee of the relevant expertise across a wide range of domains. The committee comprised 12 members, including two co-chairs. Specific expertise was provided on staffing modeling, management of VHA and other facilities, industrial-organizational psychology, management of human resources, and human-systems integration. The committee was drawn from industry, the armed services, academia, and consulting organizations.
The committee’s data gathering and analysis occurred through five planned meetings between September 2018 and August 2019. These meetings included data accumulation and development of findings and recommendations, with the balance moving from former to latter as the meetings unfolded. At one meeting, a VHA facility was visited so that the committee could have a firsthand experience of how facilities staff organized and performed its tasks. At the time of this report, five workshops had been held to cover topics essential to the committee’s deliberations
(NASEM, 2019a,b,c,e,f). They included speakers from VHA, other comparable organizations, the community of staffing modelers, and auditing bodies relevant to VHA operations. VHA liaison staff attended these workshops and the open parts of the meetings as a way of informing them of the factors that needed to be considered in developing staffing models, and of the models that had already been used successfully in other organizations. The committee sees this report as the guidebook requested in the statement of task. Short summaries of the workshops and open meetings are given in Box 1.2.
INTERIM REPORT
For this study, an interim report was required and produced (NASEM, 2019d). The interim report was designed to provide early guidance for the sponsors to allow them to move ahead with long-lead-time items necessary for implementing a staffing model, particularly data availability and quality. As noted in the interim report: “This interim report focuses on the types, availability, usage, and limitations of models in the staffing processes. Because this is an interim report, recommendations provided in this report are limited to model data” (NASEM, 2019d, p. 1). All of the sections and insights from the interim report have been expanded in this final report to ensure that the points in the statement of task and the reviewers’ comments on the interim report are all addressed.
The interim report noted that task lists for the three main functions of Facilities Engineering are O&M; Capital Projects project management and project delivery; and Engineering Administration. Note that typical VHA Facilities Management (Engineering) departments consist of engineering administration, project management, maintenance skilled trades, grounds maintenance, operation of high-pressure steam, operation of chiller plants, biomedical engineering, and safety (including overall medical center safety, fire safety, emergency management, industrial hygiene, and Environmental Protection Agency compliance). In some facilities, there may be additional maintenance activities required for research laboratory and medical equipment. Maintenance can also include regular sustainment and restoration projects—such as air handling replacements, an overhaul of patient areas, or comprehensive relamping—for which planning and oversight may be different than larger capital projects. Since staffing models already exist for the safety program and biomedical engineering, these are not included here except as they impact the other functions such as engineering administration (NASEM, 2019d).
The interim report also discussed the importance of staffing models for VHA noting that the following:
The Federal Property Management Reform Act of 20162 requires federal agencies, with respect to the use of federal real property, to perform workforce projections to assess the property-related requirements of the federal workforce. Apart from this obvious mandate, a staffing model enables quantitative planning of VHA Engineering staffing targets, which in turn provides the foundation for human resources activities. Qualitative aspects of workforce planning are dealt with through other processes. Such a model can be used at various levels of aggregation—specifically at the overall (national) VHA level, at the Veterans Integrated Services Network (VISN) level, and at the site director level. At the national level, use of models support exposition of data used in presentations made to Congress for changes in staffing levels (increase or decrease) based on the known requirements for building/system inventory, required service levels, and current staffing, which in turn can be used to prepare and justify VHA budget requests. Also, at the national level, such a model provides a tool for VHA compliance engineers to determine whether adequate staff is available to comply with U.S. Department of Veterans Affairs (VA) directives and program requirements. At the VISN level, a model can be used to equitably allocate staffing resources between sites, as these same parameters change at the site level. At the site level, the director would have quantitative access to where facilities engineering demands are likely to exceed current staffing in coming years so that funding resources can be allocated optimally between the various functions within a VHA site. Any staffing model should be able to guide leadership at all three levels.
The interim report had the following findings and recommendations on the underlying data required to populate and validate any subsequent staffing model (NASEM, 2019d, p. 12):
Finding 1: Accurate data regarding the functional and physical characteristics of VA facilities is required in order to implement a staffing model for Facilities Engineering.
Finding 2: Any database used for a staffing model needs also to include staffing and outcome data relevant to Facilities Engineering performance.
Recommendation 1: The Veterans Health Administration should ensure that the choice of platform of facilities database is given careful consideration to ensure continual completeness, accuracy, reliability, and validity of the data.
Recommendation 2: Policies, procedures, and training for entering and updating information for any comprehensive database, such as the Capital Resource Survey (CAPRES), and work order data should be implemented by the Veterans Health Administration to support staffing and other management models.
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2 Public Law No. 114-318, Federal Property Management Reform Act of 2016, H.R. 6451, 114th Congress, December 16, 2016.
RATIONALE FOR MODELING
The Federal Property Management Reform Act of 2016 required federal agencies, with respect to the use of federal real property, to develop workforce projections to assess the property-related requirements of the federal workforce. Apart from this obvious mandate, a workforce projection based on a valid staffing model allows for quantitative planning of staffing, guiding hiring, training, retirements, and personnel transfers within VHA Facilities Management (Engineering). Modeling can be aggregated and used at various levels: VHA-HQ, Veterans Integrated Service Networks (VISN), Veterans Administration Medical Center (VAMC) director, and the chief engineer. At the national level, a model would allow for the case to be made to Congress for changes in staffing levels (increase or decrease) based on the known requirements for building/system inventory, required service levels, and current staffing. At the VISN level, a model can be used to allocate staffing resources among sites as these same parameters change at a site level. At the VAMC, the director will have quantitative access to where facilities engineering demands are likely to exceed current staffing in coming years so that funding resources can be allocated optimally among the various functions within a VHA site. Below this level, the chief engineer at a VAMC will be able to project detailed staffing needs. Any staffing model should be usable at all four levels.
As an example, current VAMC directors have said that they typically allocate most of their funding budget but keep some in reserve for dealing with unforeseen events or emergencies. Any excess in the emergency portion can be allocated to a list of shovel-ready projects at the end of the fiscal year, but this may not be optimal. Directors have many demands on their limited budgets beyond facilities engineering but have staffing models only in some specific professional areas such as nursing or occupational safety and health. Knowing the demands for continued safe operations and tolerable risk levels, directors can make more informed decisions about budget allocation and reserve/emergency amounts. This would be a more valid procedure than the current reliance on past staffing and “feel,” as one director put it to the committee. Naturally, these uses of a facilities engineering staffing model demand that a valid and reliable model be developed and implemented. Any such model must also recognize that staffing cannot be changed instantly: staffing levels have inherently more inertia than budget dollars because of the time lag in recruiting and hiring replacements.
REPORT STRUCTURE AND SUMMARY
The structure of this report reflects the committee’s methods and analysis. The current chapter provides an overview of the problem as described in the statement of task (See Box 1.1) as well as the approach taken by the committee. Chapter 2 provides extensive detail on how facilities are managed and the key drivers and expertise needed to run a medical facility. In Chapter 3, several critical features of models and the characteristics desirable in models are discussed. These features and characteristics are then discussed in the context of staffing models. Chapter 4 describes a resource planning and staffing methodology for VHA Facilities Management (Engineering) programs. It can be used by VHA to estimate staffing needs in each of the three functions described as in-scope by the sponsor: Engineering Administration, Capital Projects, and Operations and Maintenance using site specific input data to produce outputs optimal for each VAMC. It includes a notional illustration of model outputs after application of the staffing methodology. Chapter 5 provides a framework for the process of implementing and sustaining the facilities engineering model to include roles for key staff elements vital to the success of the model. It also suggests critical items for the sponsor to consider during a recurring review of the methodology to ensure it reflects the changing needs and structure of the VHA Engineering workload. Appendix A lists the agendas and speakers for the committee’s various data-gathering workshops and meetings held to fulfill the statement of task. Appendix B covers the committee members’ biographies. Appendic C concentrates on the VHA’s Facilities Management structure to cover operations both with VHA staff and with external contractors. It describes the portfolio of facilities that must be managed, maintained, replaced, and expanded or eliminated. Appendix C helps define the complexity of the VHA Facilities function in terms of the health care and related medical services at each location and the great variety of buildings and systems across the enterprise.
