5

Design, Implementation, and Sustainability of the VHA Facilities Management (Engineering) Staffing Model

INTRODUCTION

Chapter 4 described the context in which the Veterans Health Administration (VHA) Facilities Management (Engineering) Staffing Model will operate and a staffing methodology that starts with a baseline and then applies infrastructure complexity parameters to capture the specific factors that impact the three Facilities Management (Engineering) functions defined as in-scope by the study sponsor. This chapter will address the considerations for a process to design, implement, and sustain the model as it operates in the dynamic context described in the previous chapter. Although the numbers generated by the staffing model justify and quantify, the actual staffing plan each medical center director approves will ultimately be a balance of risk versus resources as he or she apply his or her expert management judgment to the model output.

The following three steps are necessary to ensure the success of this staffing model: the appropriate design of the model, the organization’s support to implement the model, and the leadership commitment to sustain the model. To start, this chapter will begin with a description of how key staff element roles could be identified to tap into critical expertise for each of these three steps. It will then provide a conceptual process and timeline to methodically design and implement the model, with attention paid to the integration of the model into the budget cycle. It will follow with a discussion of resources, to include leadership engagement—necessary to implement and sustain the model—as well as a summary of sustainment considerations to support a recurring update of the model. Last, it will offer areas for further study on issues the committee believes could impact the VHA Facilities Management (Engineering) staff, and thus the model, in the near future. Once developed, the model output should provide a defensible Facilities Management (Engineering) staffing requirement to support annual budget requests and then inform staffing decisions to best manage risk at the medical center level based on actual funding. The optimal budget and staffing levels are those which meet the performance goals established for the facility at the lowest cost to the taxpayer.

KEY STAFF ELEMENT ROLES

Sponsorship and Oversight

The committee heard several briefings from within the Department of Veterans Affairs (VA) organization to include the VHA Headquarters (HQ) and the sponsoring office, Office of Capital Asset Management, Engineering,

and Support (OCAMES) (Broskey, 2018, 2019). Based on the role and responsibilities of OCAMES, it would be logical that this office would continue to be the sponsor and provide oversight and management for all steps of the model.

Leadership Champion

The senior leadership champion is the Deputy Undersecretary of Health for Operation and Management. Throughout the workshops and meetings, the committee gained an understanding of the pivotal role of the medical center director in prioritizing resources to successfully accomplish the VA mission at his or her medical center level and also heard directly from a panel of medical center directors themselves. Because the model provides insight into the unique infrastructure attributes at the individual medical center, it becomes a powerful tool for each director to manage risk as he or she makes staffing level decisions for his or her Facilities Management (Engineering) department. As such, the medical center director is the logical leadership champion to provide positive emphasis to the model effort and consistent communication to the workforce on each step.

Permanent Chief Engineer Facility Advisory Council

Throughout the meetings, workshops, and panels, the committee also gained an appreciation for the vital expertise of the chief engineers. Committee members with professional expertise in facilities management suggested regularly soliciting input from chief engineers on strategic issues beyond their specific facility or location. This forum could be referred to as the Chief Engineer Facility Advisory Council (CEFAC), and VHA should consider convening the CEFAC on a recurring basis, potentially quarterly. Among others, it could include an experienced chief engineer from each Veterans Integrated Services Network (VISN) to foster representation and communicate with an entire region. This body would be integral in the design, coordinated review, implementation, and sustainment of the staffing model (see Figure 5.1). It would also support OCAMES in overseeing annual reviews of the VHA Facilities Management (Engineering) Staffing Model. The committee received input that a forum similar to this existed at one time, so there is a precedent for it. It may provide an effective group to represent the facility maintenance aspect of issues, ensure that facility considerations are integrated into strategic VHA initiatives, review policy from a facility aspect, share lessons learned on risk mitigation and efficient resource allocation, as well as address countless other issues.

RECOMMENDATION 5.1: The Veterans Health Administration (VHA) should form a standing body of experienced chief engineers to meet on a routine basis, potentially quarterly, to share insights and help shape the overall VHA Facilities Management (Engineering) mission in order to continually best support VHA strategic initiatives. This body would serve as a Chief Engineer Facility Advisory Council and support each step of the VHA Facilities Management (Engineering) Staffing Model to include assisting the Office of Capital Asset Management, Engineering, and Support (OCAMES) in overseeing the VHA Engineering Staffing Model annual reviews.

Subject-Matter Expert Task Force

The committee heard from successful staffing modeling efforts such as the VHA Nursing Staffing Model and the VHA Safety and Occupational Health models, as well as National Academies of Sciences, Engineering, and Medicine committee findings on staffing models for other Facilities Management (Engineering)-type work in other federal agencies, such as the Federal Aviation Administration (FAA) staffing model (Delaney, 2019a; Taylor, 2019). These models leveraged a task force of subject-matter experts (SMEs) in the design of the model. In the committee’s judgment, this would be an effective approach for the design of the VHA Facilities Management (Engineering) Staffing Model as well. The approach would have VHA identify a task force of experienced VHA Facilities Management (Engineering) SMEs in each of the three functions (Engineering Administration, Operations and Maintenance, and Capital Projects) to develop the fundamental workload estimates that underlie

the model, as well as the parameters, thresholds, and recommended staffing variances in the initial model. The Facilities Management (Engineering) SMEs will provide institutional knowledge and insight on the estimated workload associated with key tasks for their function.

In addition to the Facilities Management (Engineering) SMEs, the task force should include appropriate “operators” such as physicians, nurses, laboratory technicians, and other key staff such as modelers (e.g., from the Manpower Management Office or the Office of Productivity, Efficiency, and Staffing [OPES]) that provide insight to the impact of infrastructure complexity parameters on their portion of the VHA mission. In particular, the operators on the task force will add their expertise on the probability and severity of “never events” (e.g., unplanned electrical power outage or unplanned unavailability of operating suites), which will help to link Facilities Management (Engineering) staffing levels with risk. Consequences of “never events” are not equal across all customer bases and across VHA missions. Therefore, staffing to mitigate risk must be done with insight on consequences

when determining the thresholds within the facility parameters. The operators could serve on an as-needed basis to the task force, but at least one should be a dedicated member to ensure consistency.

RECOMMENDATION 5.2: The Veterans Health Administration (VHA) should establish a task force of experienced Facilities Management (Engineering) subject-matter experts with significant experience within each of the three functions for the initial design of the VHA Facilities Management (Engineering) Staffing Model. The identified personnel should also represent experience across an appropriate range of medical center sizes, missions, and locations (e.g., small, medium, large, rural, metropolitan, facility complexity levels 1a to 3).

RECOMMENDATION 5.3: The Veterans Health Administration should include appropriate “operators,” such as physicians, nurses, laboratory technicians, and other key staff to include modelers to augment the task force of Facilities Management (Engineering) subject-matter experts on an as-needed basis, but with at least one being consistently dedicated to the task force. The operator insight should include but not be limited to the impact of facility failure on the mission set and thus add perspective on the likelihood and consequences of “never events” that can occur if Facilities Management (Engineering) staffing levels are too low.

Throughout this study, the committee was impressed with the judgment of the VHA Facilities Management (Engineering) staff as they made management decisions in a resource-constrained environment. It is the committee’s view that a well-developed model will contribute to the decision process, not replace the judgment of experienced professionals. To this end, the model should inform the decision maker, not replace them. In addition, while the model should provide full-time equivalents (FTEs) based on the existing workload, the decision on whether to hire FTEs, contract out, or combine tasks for efficiency will necessarily be based on human judgment informed by the model. These decisions are impacted by a myriad of considerations, often local, which include availability of talent for hire, access to contract options, and risk the facility is willing to accept based on competing demands. In the end, the model will not provide hard and fast answers to staffing, and the judgment of seasoned professionals will still be required.

DESIGN PROCESS AND TIMELINE

Overview

The design process includes phases with an associated time frame, as depicted in Figure 5.2. The phases consist of an initial design (12 months); a coordinated review of the initial design that results in a coordinated working

model (6 months); and an independent validation of the working model that results in the VHA Engineering Staffing Model 1.0. (12 months). Based on similar staffing model efforts, such as the National Academies report on the FAA Systems Specialists in Aviation, as well as committee experts, the estimated design time of approximately 30 months is an ambitious but reasonable timeline given the extensive data already available and preliminary analyses that have already been conducted on this topic (NRC, 2013).

Phase 1: Design of “Initial Model” (12 Months)

The design process starts with the SME task force developing an “initial model” based on workload estimates that lead to baseline staffing levels, and staffing variances that reflect key ways in which Facilities Management (Engineering) workload varies across Veterans Administration Medical Centers (VAMCs). Although the framework of the model is provided through the methodology, the SME task force will have considerable work to do as they assess and agree on baseline staffing levels, the relationship between staffing and performance, and then the set of infrastructure parameters, thresholds, and staffing variances (as described in detail in Chapter 4). The parameters and thresholds for each parameter across each staff category will comprise, at a minimum, the VHA Facilities Management (Engineering) Staffing Model.

The first step of this effort is to determine a baseline level of staff also described in detail in Chapter 4. The baseline is the level of staff that the least infrastructure intensive medical center would require. It is the starting point from which to add the infrastructure complexity parameters and thresholds to build out the staffing level, by function, for different configurations of infrastructure complexity across the 172 medical centers.¹

Once the baseline is established, the SMEs will assess and agree on a set of parameters that best capture the most important infrastructure complexity characteristics that impact Facilities Management (Engineering) workload. They will then logically determine threshold(s) within each parameter that warrant a variance of additional staff, striving for at least three threshold levels (A, B, and C) for most parameters. (For some parameters, the viable choices may only be present/absent—for example, whether there is or is not a water treatment plant at a given VAMC.) The staff variance values will be estimated in terms of FTE employees, and estimated separately for each threshold of each facility parameter for each of the three major functions (Engineering Administration, Operations and Maintenance, and Capital Projects), and possibly even at the level of specific jobs. This creates multiple points for adjusting the model, as needed, based on future reviews. (See Figure 4.6 in Chapter 4 for an example of what this initial model might look like.)

Along the way, the SME task force may do some reality checking by profiling a few VAMCs on the initial model infrastructure complexity parameters and using the thresholds and variances to calculate recommended Facilities Management (Engineering) staffing levels for those VAMCs. These values could be compared with actual, known staffing levels for the VAMCs. It is important to note that if the model estimates do not closely align with the current, actual staffing levels, this does not automatically mean that the initial model is “wrong,” because current actual staffing levels may not be optimum. Rather, it could prompt more thinking about the parameters, thresholds, and staffing variances to ensure that the SME task force can explain how and why they believe their work is on target. It is reasonable to expect that medical center directors, chief engineers, and VHA senior leadership will more closely scrutinize a model that leads to staffing estimates quite different from current staffing levels (either higher or lower).

The committee recognizes that the SME task force will need to deal with three major challenges that were described in the interim report and in previous chapters of this report, as follows:

1. In at least some instances, the task force will likely find that the data for an important parameter (a) are not sufficiently reliable or valid (see Chapter 3); (b) are not being captured or are not accessible to Facilities Management (Engineering) personnel; or (c) cannot be easily or quickly improved. Thus, the SME task force will likely require guidance and assistance from OCAMES or OPES to determine if there are viable

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¹ As of April 2019.

2. alternatives. In reality, it is possible that the initial model will need to exclude an important infrastructure complexity parameter until high-quality data can be located or collected.

3. VHA Engineering does not have a clearly defined set of performance-level standards for the provisional SME task force to use as a target for estimating baseline staffing levels or staffing variances. Until such levels are provided, the task force will need to articulate a set of working definitions of performance levels to guide their work and to foster transparency in how the estimates were derived (see Chapter 4) (GAO, 2019).
4. VHA may have potential gaps or conflicts in policy that need to be resolved or clarified. For example operating room suites are a crucial element of hospitals. They are expensive to maintain and run and drive large infrastructure and nursing staff requirements beyond the operating room suites (i.e., surgical preassessment and counseling, anesthesia, ambulatory care unit, post-anesthesia care unit, phase II recovery unit, sterile processing, etc.). For a government facility, since most labor is considered fixed, the staff will be present and paid regardless of the amount of work performed. Humidity and temperature control in operating room suites is a mandated quality and patient safety requirement. The Joint Commission mandates 100 percent preventive maintenance on critical systems, such as HVAC for operating rooms. Therefore, 100 percent HVAC preventive maintenance by engineering staff is required. Within government, human resources (HR) has often fought individual performance objectives that mandate 100 percent as the minimum standard. If HR will only support performance objectives with 90 percent compliance as sufficient to meet—or exceed—the standard, clearly this creates a policy-driven problem for the chief engineer to mitigate. In patient care, it is usually recognized that provision of quality and safe patient care by clinicians is expected to be perfect. Some publicly available data (see DoD, 2019) include the following:
   • Wrong Site Surgeries in FY 2018 = 45. This is out of 40,370 surgical procedures (error rate = 0.00111).
   • Unintended Retained Foreign Object (URFO) = 27 out of 40,370 surgical procedures (error rate = 0.00066).
   • Interoperative or Immediate Post-Op/Post-Procedure or Surgery = 11 out of 40,370 procedures (error rate = 0.00027).

From a policy perspective, imagine if the accepted standard for clinicians were only 90 percent. Health care can be an inherently dangerous endeavor, and patient safety demands as close to perfection as possible from all staff members, including those in administration and VHA Facilities Management (Engineering).

These challenges should not be seen as roadblocks to progress on the initial model. Instead, it should be recognized that the model will be a living tool that is refined during annual review as these challenges get addressed. As such, insights gleaned from the SME task force during model development should be documented and shared with the CEFAC and the model sponsor for their review, guidance, and action, as appropriate, regarding topics such as potential data quality gaps, enhancement, and suggested corrections; observations for Facilities Management (Engineering) performance level standards and associated key performance indicators (KPIs). Ultimately, this should help improve Facilities Management (Engineering) operations across VHA and improve the accuracy of the VHA Engineering Staffing Model over time.

RECOMMENDATION 5.4: The Veterans Health Administration subject-matter expert task force should document areas of data quality gaps, enhancements, or suggested corrections; observations for potential Facilities Management (Engineering) performance-level standards and associated key performance indicators; and potential policy gaps. The task force should provide this information to the Chief Engineer Facility Advisory Council and the model sponsor for their review, guidance, and action as appropriate. Attention to data accuracy, performance metrics, and consistent policy will directly enhance the accuracy of the model.

As mentioned in Chapters 3 and 4, transparency is paramount to the success of the VHA Facilities Management (Engineering) Staffing Model. All stakeholders should be able to see and understand the logic and justification

behind the baseline staffing FTE estimate. They should also be able to readily understand the infrastructure complexity parameters and how/why those add to the workload for Facilities Management (Engineering) staff. Critically, the data on which the estimates are based and the expertise of the SMEs who made judgments should be apparent to eliminate concerns that the model is based on more than just the intuition of a few Facilities Management (Engineering) staff members. Last, all stakeholders should be able to see the logic behind the thresholds for each parameter and the logic or justification for the staffing variances for each threshold of each parameter. The SME task force must be methodical and comprehensive in its documentation of the model design. This will enable a thorough and efficient review during Phase 2. It will also create the foundation for an annual review of each element of the staffing model as it is compared to current staffing levels and adjusted to account for changing conditions or data availability.

RECOMMENDATION 5.5: The Veterans Health Administration (VHA) subject-matter expert task force should apply the VHA Facilities Management (Engineering) Staffing Methodology to determine and document all logic, justification, and calculations for the baseline, parameters, thresholds, and variances when building out the initial VHA Facilities Management (Engineering) Staffing Model. The baseline, parameters, thresholds, and variances should be annotated in a transparent manner that facilitates clear review and coordination during development to ensure that the design is robust and the logic is sound. In addition, the documentation should facilitate an annual review where the baseline, parameters, thresholds, and variances can be reevaluated for relevancy and adjusted, added to, or eliminated as circumstances change.

Phase 2: Coordinated Verification of Initial Model (6 Months)

Transparency also involves the deliberate review of work products by appropriate staff and echelons within any organization. Therefore, after the SME task force has completed the design of the initial model, the model should then undergo a coordinated review. The SME task force will continue to be involved at this stage, by briefing reviewers, answering questions about its work, and addressing recommendations and challenges. The committee suggests that the SME task force starts by hosting a review by a small team of senior expert representation from OCAMES, medical center directors, and the CEFAC to obtain an azimuth check on the initial model before it begins a more rigorous review and coordination process. It would be effective to have the SME task force present its initial model to this senior expert team to ensure that it is appropriately aligned with agency goals and strategic vision. The estimated time for conducting this preliminary review and incorporating the feedback into the initial model is 1 month.

With support from the medical center directors and CEFAC, the SME task force should then use a coordinated review process to have all medical center directors and chief engineers vet the initial model. This coordinated review should include a few examples of actual VAMC Engineering Staffing Model outputs. This will give concrete examples to make the review easier to understand. Of note, the VHA Engineering Staffing Model output differs from that of the Facility Complexity Model. The Facility Complexity Model provides output for each VAMC that is along a compendium of five possible options, known as the Clinical Complexity Index (1a, 1b, 1c, 2, 3). The VHA Engineering Staffing Model provides output (staffing requirements) that is specific if not unique to each VAMC based on the parameters, thresholds, and variances that represent that VAMC’s specific infrastructure complexity.

The committee estimates that this review process will require 3 months. The SME task force would then use the remaining 2 months in Phase 2 to incorporate additional feedback and produce a coordinated working model, assuming that there is general support from reviewers about how the model works and the output it produces.

Phase 3: Coordinated Working Model Independent Entity Verification (12 Months) and Validation

In the FAA staffing studies (NRC, 2007, 2013), an independent third-party validation was a recommended step in the review and validation of the staffing models. As such, the committee encourages VHA to conduct an independent third-party validation of the Engineering coordinated working model by an entity with expertise in

manpower analyses. The third party may be an office or a function with VHA or an outside vendor. The key is that the third-party entity should have no stake in the outcome of the staffing model. The third-party entity would review all data sources and logic algorithms. The entity would then run scenarios for all 172 VAMC Facilities Management (Engineering) departments,² taking care to exclude the functions that are not included in the model. This process will mirror some of the scenarios likely enacted in Phase 2, but the difference is that the third party has no vested interest in how closely (or not) the model outputs match current Facilities Management (Engineering) staffing levels.

The independent third-party validation will also review the reviewer comments from Phase 2 and provide insight on whether the most relevant comments were incorporated in the model based on the data analytics. By the tenth month of Phase 3, the entity will provide a series of briefings to the appropriate stakeholders and leadership in an appropriate order, incorporating feedback after each session (e.g., the SME task force; the CEFAC; the model sponsor; the medical center directors and chief engineers by VISN). Upon successful completion of coordination and formal model acceptance, the entity will publish the model as VHA Engineering Staffing Model 1.0 and all of its supporting documentation in a format easily reviewed and updated on an annual basis.

RECOMMENDATION 5.6: The Veterans Health Administration should employ an independent entity to conduct a validation analysis on the task force methodology and output that includes a review of the data sources and algorithms; comparisons of performance predictions with observed performance where that data are available; an analysis of scenarios for all Veterans Administration Medical Center Facilities Management (Engineering) functions; assessments of the comments from the Phase 2 coordinated review of the initial model; status briefings at each appropriate echelon and publishing for the model upon final approval within approximately a 12-month time frame.

IMPLEMENTATION PROCESS AND SUSTAINMENT CYCLE

Organizational Support and Leadership Commitment

Successful implementation and sustainment of the VHA Facilities Management (Engineering) Staffing Model hinge on the organization’s support of and leadership commitment to the model and the subsequent changes it will drive. Transparency, as well as deliberate, inclusive coordination of the model during the design phases, will help build organizational support, as will the understanding that every year the model will be assessed and updated to refine the features of the model or the data on which they are based, and to take into account context changes that significantly impact Facilities Management (Engineering) workload. However, the strongest action to galvanize organizational support will be consistent communication from leadership as they begin to take actions based on the model output that may change the status quo. To demonstrate this leadership commitment, it will be helpful to have strategic communications across the organization and especially at the medical center level in advance of major actions to reassure the workforce and minimize uncertainty. It may be helpful to have human resources support and advice on the communications to ensure that appropriate information is included to answer anticipated personnel action questions. Effective communication is vital in change management, and change management is a leadership-driven endeavor that is paramount to the successful implementation of a staffing model. Change management is discussed in more detail later in this chapter because of its critical importance to the entire effort.

Synchronizing Implementation and Sustainment with the Budget Cycle

The implementation of the model is inextricably linked to the budget cycle. Implementing staffing actions will be dependent on the levels of funding the medical centers receive for Facilities Management (Engineering) staff. Nearly any action that changes the status quo will require resources, whether it be hiring, realigning, contracting, or reducing Facilities Management (Engineering) staff.

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² As of April 2019.

Once the design phases are complete and VHA leadership is ready to proceed, the implementation may begin. It may logically start with the medical center directors assessing the output of the model and using it to inform their prioritization of engineering staffing requirements against their current levels of funding. Depending on the point in the fiscal year that implementation begins, there will likely be windows of opportunity to reprioritize resources in the budget cycle (e.g., first quarter, when the appropriation is passed; second and third quarters, when midyear execution is reviewed and funding may get realigned; fourth quarter, when the end of year execution is reviewed and funding may get realigned).

Since the purpose of the model is not only to assist medical center directors to manage risk within current funding levels but also to support the department’s budget request to Congress, it must be synchronized with the budget cycle to be effective. Informing the budget request to Congress is likely only one window depending on when the VA submits its department’s budget request for the next fiscal year, commonly known as the “President’s Budget” and usually done in the February time frame.

The tasks involved in sustaining the model will logically be similar to those needed to implement the model, because the goal of both is to help manage risk at the medical center level and inform the budget request at the department level. The difference is that the sustainment steps will include the full-scale annual review of the model as well as any other annual assessments that would provide insights to the medical center director on how to best apply the model output—for example, performance metrics, trends in execution of Facilities Management (Engineering) staffing funding, and risk management issues. These steps begin to flow into a continuous cycle synchronized with the organization’s budget cycle. For these purposes, it may be helpful to visualize an implementation process and sustainment cycle in the context of the fiscal year. Table 5.1 provides a notional implementation process and the follow-on sustainment cycle.

Table 5.1 offers suggested actions and timing to synchronize the model life cycle into the budget development and execution cycles. The medical center directors, as champions and primary benefactors of the model, will need to ensure that the cycle that is adopted is synchronized to best inform their decision-making cycles and the timing of the department’s budget request to Congress. Note that the first review of the model is suggested in the first year of implementation and labeled as an “initial” review. This provides the organization an opportunity to adjust anything that may have emerged since the original design and gets the sustainment cycle on track.

RESOURCES

VHA Facilities Management (Engineering) Staff Investment

Implementation of this staffing model will require an investment that should be transparent in both the budget request and the distribution and execution of the appropriated funds. Once the model provides a Facilities Management (Engineering) staffing requirement at each VAMC, those figures should be aggregated at the department level without losing fidelity of function and location to support the department’s budget request to Congress. In order for the model to retain relevancy, there should be an audit trail of this aggregated model output, the percentage of funding requested by the department of the aggregated output and then the percentage of funding appropriated by Congress for the VHA Facilities Management (Engineering) staff of the aggregated model output. It would be logical for the department to then distribute the funding for the Facilities Management (Engineering) staff out to the VAMCs in a manner that is proportionately consistent with the percentage each VAMC “earned” in the model in the event Congress appropriated less funding as appropriate.

Once the medical center directors receive their funding, it is their decision on how the funds are executed. However, a review to compare the amount of funds distributed to the medical center for Facilities Management (Engineering) staff against the amount of funds executed for Facilities Management (Engineering) staff should be conducted. This is a prudent measure to identify issues such as hire lag or funds migration. This review also helps to inform the medical center directors on potential adjustments they may want to see in the model or potential internal controls for funds execution.

Careful consideration should be given to the civilian grade of the Facilities Management (Engineering) functions at each VAMC. The environment of care is directly dependent on operational facilities. The risk associated

with infrastructure to the VHA mission and operations must be aligned with appropriate expertise and compensation. This is especially important for talent management and retention. Last, this staffing model should not compete with infrastructure investment but rather be balanced with the infrastructure investment to ensure its successful implementation.

RECOMMENDATION 5.7: The Veterans Health Administration (VHA) should conduct a review of facility workforce funding that is modeled by the VHA Facilities Management (Engineering) Staffing Model to identify potential issues such as hire lag or funds migration in the process (1) identified at the individual Veterans Administration Medical Center (VAMC) level and aggregated to the VHA Headquarter level; (2) requested by VHA Headquarters to Congress; (3) appropriated by Congress; (4) distributed by VHA Headquarters to the Veterans Integrated Services Network (VISN); (5) distributed by the VISN to the VAMC; and (6) executed by VAMC.

ANNUAL REVIEW

A regularly occurring review of the model parameters, thresholds, and variances is paramount to sustaining the facility staffing model. Leadership from each level of the VHA chain of command will need to ensure the integration of this model review into their planning processes with the actual review being overseen by the model sponsor and supported by the CEFAC. Most importantly, it must be championed by the medical center directors. The model is their tool to inform them of appropriate Facilities Management (Engineering) staffing considerations, just as the Nursing model is their tool to inform them of nurse staffing needs. Ideally, the Facilities Management (Engineering) Staffing Model can help medical center directors adequately address risks to timely, safe health-care delivery based on the unique infrastructure requirements of their medical centers. The timing of the staffing model review should occur annually in time to provide defensible requirements to support the budget request to Congress.

The annual review should consider all model assumptions and estimation procedures (e.g., baseline staffing level, infrastructure complexity parameters, threshold values, and staffing variances). It should also consider the emerging factors that could impact those assumptions and estimation procedures, such as programmed facility investment or changes in Joint Commission requirements. For example, new construction coming online could impact the outputs of the VHA Engineering Staffing Model, because the workload for Facilities Management (Engineering) staff will be impacted. Because of the criticality of the Facilities Management (Engineering) staff to overall hospital safety, the VHA Facilities Management (Engineering) Staffing Model should be kept up to date with all major decisions in hospital operations. These factors include but are not limited to the following:

1. What is the status of the infrastructure investment (is there a significant increase or decrease of facility investment or construction at a medical center)?
2. Have other staffing models been updated and will that impact the Facilities Management (Engineering) staff workload—for example, tasks that used to be performed by Nursing now pushed to Facilities Management (Engineering)?
3. Changes of infrastructure at the medical center level:
   1. Condition
   2. Age
   3. Unique requirements or new requirements (i.e., traumatic brain injury or post-traumatic stress disorder care)
   4. Demographic population shifts (i.e., gynecological care for the growing number of female veterans)
   5. Leased status (i.e., community-based outpatient clinic locations and capacities)
   6. Contracting requirements
   7. Hospital service planning
4. Changes in strategic plans for hospital missions (i.e., being subsumed by a larger VAMC or experiencing reductions in clinical services offered).
5. Outputs of an infrastructure investment strategy (described below).
6. Changes in Joint Commission or other compliance requirements.
7. Changes driven by artificial intelligence (AI) initiatives or the application of big data analytics (BDA).
8. Results of root cause analysis of any facility failures and adverse facility events that occurred that year.
9. Results of performance metrics and measures that occurred that year.
10. Adoption of process changes described in the section “Areas for Further Study” later in this chapter.
11. Whether contracting options may be more effective than full-time employees for certain skill sets.

VHA LEADERSHIP AND KEY STAFF

As discussed earlier, VHA leadership support is integral to the success of every step of this model from design through sustainment. Leadership commitment is especially important to sustain the model in order to preserve its relevancy and acknowledge the importance of the facility engineering staff to the overall VHA mission. Implementation and sustainment of the model will require continued emphasis to maintain momentum on this effort. This likely involves to some extent a culture shift.

Change Management

The conventional wisdom is that staffing models are all about the numbers. Modelers spend a great deal of time ensuring that they have the right analysis and getting it out to key stakeholders with the assumption that stakeholders will immediately understand the utility and application of the model and begin to make better decisions. Even with well-intentioned decision makers with an inclination toward numbers, this is rarely the case. The numbers are only part of the answer. The fundamentals of change management are even more critical for success than the numbers themselves. Creating very sophisticated models is a waste of time if decision makers are not willing to buy into the premises and act on their findings (Motion, 2019; NASEM, 2019e). Therefore, having a well-thought-out-strategy on how to help key stakeholders understand, commit to, accept, and embrace the results of any staffing modeling effort is critical.

The change management literature is rich with theories, approaches, and step-by-step processes for successful change. Typically, change management strategies employ a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits. Successful change management is more likely to occur if the following steps are included:

1. Define a clear vision that can help stakeholders understand what the organization is trying to achieve within the agreed time frame.
2. Closely monitor potential assumptions, risks, dependencies, costs, cultural issues, and so on that could impact progress toward achieving the vision.
3. Effectively communicate the vision to create support and acceptance among the various stakeholders. This should include the reasons for the change, the benefits of successful implementation, as well as the details of the change.
4. Anticipate and remove obstacles that could undermine the vision, particularly from stakeholders who will be impacted by the change. To encourage acceptance, it helps when stakeholders’ ideas are incorporated and implemented in the change process.
5. Create short-term wins so that the stakeholders have a clear idea of what is going on. Nothing motivates more than success, particularly from those closely involved in the change process.
6. Provide support in the way of training, education, or skills upgrading that is consistent with the change that is required by stakeholders.
7. Monitor implementation and adjust it as necessary. Regular evaluation and discussions about progress help consolidate the change.

RECOMMENDATION 5.8: The Veterans Health Administration (VHA) leadership at the Deputy Under Secretary for Health for Operations and Management should actively supports the design, implementation, and sustainment of the VHA Facilities Management (Engineering) Staffing Model, including a deliberate annual review of the VHA Facilities Management (Engineering) Staffing Model.

RECOMMENDATION 5.9: After the model is through the design and validation phase, the Veterans Health Administration should issue a policy for implementation and sustainment of the model, including the annual review. The implementation should be done in appropriate phases at each Veterans Administration Medical Center so that results of the early implementers can be evaluated in the annual review.

VHA Key Staff

Key VHA employees will be involved in the design, coordinated review, implementation, and sustainment of the staffing model, most notably the chief engineers and the SME task force, including participation by “operators.” They also have a responsibility to support the effective communication of the model through its design and implementation stages. Sustaining the model requires insight and observations relevant to the success of the VHA mission and thus can and should be inclusive of key staff input.

Human Resource Support

Human resource staff expertise is a critical element in recruiting and hiring qualified individuals to achieve the staffing levels recommended in the VHA Facilities Management (Engineering) Staffing Model. The committee heard repeatedly that this is no small or easy task, but it certainly is a requirement for the staffing model to work. Impacts of initiatives related to recruitment, intern programs, training, and retention programs need to be part of the discussions and incorporated as appropriate. Once the model is in the implementation phase, the human resource staff will be relied on to support the adjustments to hiring and potentially relocating facility staff in accordance with the model and medical center director guidance.

Labor Relations—Union Considerations

The committee recognizes that the staffing methodology discussed in this report may have impact to staffing levels. This may trigger requirements to inform the appropriate VHA union(s). The committee is not aware of the specific relationships that VHA has with its union(s) and has not reviewed any associated collective bargaining agreement(s). VHA should consider union involvement, both timing and extent, to ensure smooth implementation of the staffing methodology and any resultant staffing model. Predecisional involvement may include the task force of Facilities Management (Engineering) consulting with the union(s) during model development. Post-decision involvement may include briefing the union(s) on the resultant model and allowing the union(s) to request impact and implementation negotiations. In any case, VHA should consider union(s) concerns regarding staffing methodology and model development.

AREAS FOR FURTHER STUDY

The committee has noted a few issues that warrant consideration for further study as they could have a significant future impact on the effectiveness of facility operations and thus impact Facilities Management (Engineering) staff. A review of these issues will likely require upfront resources that would then result in follow-on cost savings and possibly reduction in manpower. These further areas of study include but are not limited to the following: infrastructure investment; data collection, accuracy, and analytics; staffing approaches; integration in strategic and interdisciplinary planning; and leveraging big data, machine learning, and artificial intelligence.

Infrastructure Investment

VHA could consider a long-term strategic infrastructure investment strategy that, unlike the current SCIP process, incorporates strategic initiatives. Such a strategy could be a major factor in the annual review of the VHA Facilities Management (Engineering) Staffing Model to ensure that it is synchronized with the overall direction of the VHA strategic plans for its footprint. A long-term strategic investment strategy may assist VHA with achieving sufficient funding to meet its infrastructure needs.

A strategic infrastructure investment strategy should consider the following issues (including, but not limited to):

1. Is facility sustainment increasing sufficiently to match inflation, and does it take into account an appropriate facility degradation factor (NRC, 2012)?
2. Is recapitalization strategically identified (i.e., renewal of the operating suites, etc.) and synchronized with the strategic vision of the VHA or VISN for that VAMC?
3. Are facility modernization and construction appropriately prioritized and synchronized with strategic initiatives that require facility changes?

The output of an infrastructure investment strategy could also be a key factor in the annual review of the VHA Facilities Management (Engineering) Staffing Model in the context of how it may inform, with longer lead time,

the increases or decreases of facility infrastructure investment at each VAMC, which in turn impacts Facilities Management (Engineering) staff workload.

Data Collection, Accuracy, and Analytics

It would be helpful to fully assess the options for a best-in-class, integrated capability for facility data collection, inventory, and analysis. Noted throughout the meetings and workshops was the challenge of effectively collecting accurate facility data across the VAMCs. Part of this challenge is the lack of an integrated application that is used enterprise-wide and only a limited use of MAXIMO. Facility staff in many cases must manually enter data into multiple systems (e.g., CAI, CAPRES, and work-order systems), creating an opportunity for human error. They must respond to requests for information from HQ that require data pulls and analyses, which may not be done consistently across VAMCs or even between staff members at the same VAMC. A further complication is that training for all of these systems and data sources is not evenly achieved. This results in a potentially undue burden on the Facilities Management (Engineering) staff and potentially impacts the organization’s ability to see itself accurately from a facility perspective. Data support multitudes of decisions and, of course, are central to deriving useful output from the VHA Facilities Management (Engineer) Staffing Model. The better the data, the more equipped leaders at every level will be for decision-making.

It would be helpful to assess the analytic approach to the SCIP process to include the data sources, required documentation, transparency, and the link to the agency’s strategic long-term infrastructure investment plan. The committee heard from presenters who indicated that, in the SCIP, projects with better-developed documentation were more likely to be funded, even if the project(s) described are not necessarily more critical or needed. This points to a potential gap in analytics. A VAMC could have a highly justified need for a construction project, but the staff may lack the time and training to put strong enough documentation together to be prioritized high enough for a construction project investment.

Staffing Approaches

The committee heard various discussions of staff approaches that could be beneficial across all VAMCs, particularly if funding is constrained. For instance, at VA Portland Healthcare System, the committee heard from a panel of tradespeople who worked on a swing shift through the night hours to complete minor renovations and not impact daytime hospital operations. They were hired on a temp/term status, giving them the potential opportunity to become permanent employees. This swing shift concept may be worthy of application VHA-wide.

Another concept worthy of consideration for application VHA-wide would be to assess where a low-density, specialized skill could be located centrally in a geographic area and support the VAMCs in that region within a reasonable commute. There could also be opportunities to increase shared skill sets with local agencies. This shared skill set concept could be further developed and overseen by the CEFAC.

The committee heard from various VHA staff about the value of the intern program, but that having the intern placed against one of their FTE positions was a challenge. It would be worthy of consideration to have the interns be centrally funded and not count against a VAMC staffing level.

The committee also heard in numerous briefings that there was a significant workload associated with contract development, execution, and oversight. It would be worthy of consideration to assess options to have Multiple Award Task Order Contracts centrally managed at the HQ or VISN level that the VAMCs could tap into. This could also achieve efficiencies by acting as a strategic sourcing of a best in class type of capability (e.g., roofing or HVAC repair). In addition, the committee heard from several service providers that offer contract options for staffing maintenance, project management, and other engineering functions. Contracting for staffing various engineering program areas can be considered as an option to deal with the difficulty in hiring qualified staff.

Also related to contracting and purchasing, the committee heard from speakers that even a minor change such as the increase in spending threshold of the purchase card would alleviate some burden on Facilities Management (Engineering) staff.

Integration in Strategic and Interdisciplinary Planning

The committee heard in discussions the importance of having the chief engineer represented in major planning efforts with interdisciplinary teams as well as strategic-level planning (NASEM, 2019a,b,c). This is a logical and prudent practice and would be wise for VHA to ensure that it is done across all VAMCs. One area, in particular, where it would be important to have a chief engineer, perhaps a member of the CEFAC, attend would be the Department of Defense (DoD) Defense Health Agency planning meetings. The vast changes coming forward from the merger of many DoD medical services under a Defense Health Agency (DHA) umbrella, where they will be streamlined and consolidated, has the potential to impact the veteran population across the country. This, in turn, could impact the VHA-owned facilities and leased community-based outpatient clinics (CBOCs). Having a senior-level chief engineer attend these coordination meetings may provide the ability to better synchronize facility access to the VA population among agencies, even though this adds to the workload of the chosen chief engineer.

Addressing these facility process changes will also need to be done in phases, with the no-cost adjustments being pursued first. Over time as these opportunities are pursued and implemented if appropriate, they may streamline parts of the facility staff workload and help offset areas of the facility mission that may cause an increase in Facilities Management (Engineering) staff.

Leveraging Big Data, Machine Learning, and Artificial Intelligence

As noted more than once in this report, VHA already captures extensive data about facilities, as well as the services it provides to veterans and the veteran population. Any organization of the size of VHA also has the potential to capture and make use of big data. The defining properties of big data include the volume of data that can be captured, the variety of data that can be captured, and the velocity or speed of processing data. Big data sources go well beyond spreadsheets and databases to include real-time capture and processing of e-mail, video, chats, and location-tracking information. It is possible to process dynamic, real-time data produced by equipment, building systems, patient monitoring devices, and so on. These data are ripe for the systematic, transparent application of advanced computational and analytic techniques such as designed machine learning, artificial intelligence, and neural networks. Many organizations are gaining new insights into their products and services using such techniques that heretofore were based primarily on human experience, judgment, and intuition. VHA could do the same and could provide a service to the public by sharing key insights. It is also important to recognize and address the potential risks associated with capturing, analyzing, and interpreting big data. These include concerns about data privacy and the ability to explain what advanced predictive algorithms are “doing” and how they work (the so-called black-box problem).

SUMMARY

This chapter provides a suggested process and timeline for the design, implementation, and sustainment of the VHA Facilities Management (Engineering) Staffing Model. Consistent throughout this chapter is the theme of transparency and communication. The chapter highlights the importance of leadership policy commitment and change management to foster organizational support for any staffing adjustments that result from the output of this model. The chief benefactor of the model is the medical center director who serves as the primary champion of the model to ensure adequate resources are dedicated to its development and sustainment. The model not only assists the medical center director in prioritizing staffing requirements and managing risk, but it also supports the department’s budget request to Congress.

This chapter provides a notional set of implementation and sustainment tasks set in the context of the fiscal year so as to directly inform budget decisions at the medical center level as the timing of the annual budget requests to Congress. Auditability of this funding request, appropriation, distribution, and execution is helpful to identify systemic issues such as hire lag or funds migration and provide fundamental insight into the applicability of the model. An explanation is provided to describe how funding for Facilities Management (Engineering) staff could

be distributed to the VAMCs in a manner consistent with the amount of funding appropriated and the percentage of the model output. Discussion is also provided on the need for a strategic infrastructure investment strategy.

The chapter emphasizes the importance of sustaining the model and offers a list of suggested items to review on an annual basis as part of that sustainment. It also discusses the importance of key staff involvement across the span of the model life cycle. Last, the chapter provides thoughts on areas for further study that could impact the facility operations and Facilities Management (Engineering) staff in the near future.

VHA is on the right track to aggressively seek a new and appropriate Facilities Management (Engineering) Staffing Model. The success of the VHA mission to provide an effective environment of care is directly dependent on well-functioning infrastructure and operational facilities. The Facilities Management (Engineering) staff in the hospital is the critical link to make this happen. Adequate staffing with appropriate expertise must be funded in an auditable manner to ensure that hiring processes can be fully planned and executed. Talent management and retention are processes that cannot afford gaps without causing significant potentially unacceptable risk to the environment of care.

With leadership emphasis and organizational support, the design, coordinated review, and independent third-party verification of the VHA Facilities Management (Engineering) Staffing Model is achievable within a 2.5- to 3-year time frame using a phased approach. Both implementation and sustainment will be most effective if they are synchronized with the organization’s budget cycle. Sustainment of the model is paramount and should be done on an annual basis and must have support at the medical center director level. Oversight of the annual review and sustainment of the model will require the expertise of experienced chief engineers in a collective body formed as the CEFAC.

The VHA’s leadership emphasis on this priority effort is highly commendable. It also illuminates the need to address related processes for further study—some that may require additional investment and some that are a matter of expanding existing business practices at no additional cost. Most notably, is the continued, deliberate inclusion of Facilities Management (Engineering) expertise in long-range planning and strategic initiatives internal to VHA. It also includes closer coordination with DHA to stay apprised of developments in its care strategy that will impact patient load and service delivery to the veteran population and thus demand facility considerations on the VHA side.