C

Nature of Veterans Health Administration Facilities Management (Engineering) Tasks and Staffing

In this appendix, the challenges to the effective performance of Facilities Management (Engineering) activities are presented, considering the portfolio of Veterans Administration Medical Center (VAMC) facilities, buildings, and systems within these buildings. Also, the mandates on Facilities Management (Engineering) beyond the capital program, maintenance, and operations are outlined. In response, the committee shows how the Veterans Health Administration (VHA) Facilities Management (Engineering) function is currently organized to meet these challenges to consider staffing models that can ensure sufficient staffing to allow the Facilities Management (Engineering) function to fulfill the needs of patients and staff throughout VHA in a safe and compliant manner. Known future challenges to any modeling efforts are also discussed.

TODAY’S VHA

VHA is the largest of the three administrations that comprise the Department of Veterans Affairs (VA), which continues to meet veterans’ changing medical, surgical, and quality-of-life needs. New programs provide for traumatic brain injuries, post-traumatic stress, suicide prevention, women veterans, and more. VA has opened outpatient clinics and established telemedicine and other services to accommodate a diverse veteran population, and it continues to cultivate ongoing medical research and innovation (GAO, 2019).

VHA operates one of the largest health-care systems in the world and provides training for a majority of U.S. medical, nursing, and allied health professionals, with about 60 percent of all VHA physicians obtaining a portion of their training at VA hospitals.¹ In addition, VA medical research programs benefit society at large. The VA health-care system has grown from 54 hospitals in 1930 to 1,243 health-care facilities today, including 172 VAMCs and 1,062 outpatient sites of care of varying complexity.² Beyond these facilities, the Veterans’ Choice Plan has opened non-VHA facilities to veterans. Because VHA requested the National Academies of Sciences, Engineering, and Medicine to devise a nationally defined program scope and breadth, adjustable based on site-specific program characteristics and inputs, it is important to determine the magnitude and diversity of the sites throughout VHA and how these are likely to change in the future.

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¹ Office of Academic Affiliations, “Mission of the Office of Academic Affiliations,” https://www.va.gov/oaa/oaa_mission.asp. Also available at https://fas.org/sgp/crs/misc/R43587.pdf, accessed September 21, 2019.

² As of April 2019.

FACILITY-LEVEL COMPLEXITY MODEL

Each of the VAMC facilities is characterized by many variables of potential importance in modeling—for example, total size, building age, and condition of building systems. Of particular importance is the widely operated measure of the clinical complexity of each VAMC.

The Facility Complexity Model is a VHA method to develop and define clinical complexity at each medical center. The VHA Facility Complexity Model brings together many variables affecting clinical complexity that are potentially pertinent to a staffing model and develops one single variable, the Clinical Complexity Index. The model was adopted for use in 1989 within the VHA Office of Productivity, Efficiency, and Staffing (OPES), and is run every 3 years on behalf of the VHA National Leadership Council (Broskey, 2018).

The methodology has remained consistent for the past three runs (since 2008), and the variables that are used to measure clinical complexity come from nationally recognized VA sources of data. It uses indexing and weighting techniques to determine an overall complexity index score for the administrative parent facility.

The model considers the following measures:

• The patient population. Under patient population is the Veteran’s Equitable Resource Allocation Methodology (VERA), which is how VA distributes money to each network and ultimately in many cases to the facility. This relies heavily on the prorated patient load. It also considers patient risk and mental health programs.
• Clinical services complexity. Measures include acute care (both the intensity of the intensive care units [ICUs] and the complexity of the surgical programs), complex clinical programs (e.g., a VA facility that runs a polytrauma center has certain complexities and support requirements that are more intensive than other facilities), and care provided in the community.
• Education and research. This looks at resident programs and includes measures such as the number of resident slots and research dollars.

The Clinical Complexity Index classifies facilities into five levels, 1a, 1b, 1c, 2, and 3, as shown in Table C.1 (Broskey, 2018). The purpose of the model is to provide peer grouping of facilities based on clinical complexity. It can be used in the program and organizational analysis for performance measures, research analysis, and operational models. The model also helps establish such incidental criteria as senior executive service (SES) pay bands for facility senior leadership teams. Regardless of its specific use, this is perhaps the only approved peer grouping tool. This complexity model is currently a major factor in the Nursing Staffing Model (Broskey, 2018).

INFRASTRUCTURE COMPLEXITY

In the VHA-owned portfolio of real property, there are 172 VAMCs organized into 18 geographically based Veterans Integrated Service Networks (VISNs). Each network has a leadership structure, and the local medical centers report to a network director, who in turn reports to a central office. In total there are 5,639 buildings, of which 2,107 are eligible for the Historic Register. The buildings total almost 153 million square feet of space (152,687,522 total gross square feet) situated on more than 16,000 acres of land (Broskey, 2018). The plant replacement value of the VHA facility inventory in the billions of dollars.

In addition, there are a substantial number of leases (1,665), primarily for outpatient clinics that were established to improve access to care. Most of the clinics provide primary care services, but some provide multispecialty and basic outpatient surgery. The total amount of leased, usable square feet is 18,617,286, costing approximately $579 million annually in rent. Thus, the Facilities Management (Engineering) function is responsible for the safe and effective operation of both buildings it owns and some oversight or maintenance responsibilities for buildings it leases. This includes Facilities Management (Engineering) monitoring and inspecting these leased buildings to ensure that lease terms regarding maintenance are met. It is also responsible for the modernization, recapitalization, and new construction of buildings and the systems they contain, all while maintaining ongoing health-care delivery to patients.

Each VAMC serves a geographical location with unique health-care needs. The VHA building inventory has medical centers of different ages, as noted above, and often there is a mix of building size, age, and infrastructure

TABLE C.1 Facility Complexity Model Definitions

SOURCE: Broskey (2018).

complexity at each site or campus (NASEM, 2019d). The buildings themselves contain a variety of functions with extremely different space and infrastructure demands. This diversity of buildings includes operating rooms, outpatient facilities, spinal cord injuries centers, research facilities, domiciliary or other long-term skilled nursing facilities, and orthopedic treatment areas. These buildings also have differing needs for utilities and contain different equipment, both building services, and biomedical systems (Broskey, 2018; NASEM, 2019e).

Specific medical centers may have requirements that are not universal, such as a fire department or a wastewater treatment plant onsite. Other medical centers may be in relatively remote areas (e.g., rural areas) where resources are few, both in terms of total staff and of the availability of outside resources such as contract workers. One staff illness in such VAMCs is far more difficult to cope with when there is only a single plumber or designer than when there are many, as at a larger, urban VAMC. This may impact the required staffing levels differently at each VAMC. Also, with the changing patient population, some buildings may not be needed but must still be maintained at some level for safety reasons. With medical centers typically comprising one or more self-contained campuses, it is not easy to find alternative uses for or to sell underutilized buildings.

SOURCES OF DATA ON FACILITIES

As in any organization, VHA keeps track of its buildings, systems, and other capital assets using a variety of databases and measures. All of these databases are useful tools for the facilities staff. The sources of data presented in this section may potentially be used as input to any staffing model designed by VHA.

VA Site Tracking Database

The VA Site Tracking Database (VAST) is the authoritative source of all VHA service sites of care, including all the leased clinics. Every location with a unique physical address is tracked in the database. It is used for

all data offices, internal and external communications, and websites. The tool, supported by VHA Headquarters, provides access for locating VHA sites of care and assists in locating service for internal customers. Additionally, the data contained within the VAST assist leadership and program offices with inquiries from Congress and other stakeholders.

Capital Asset Inventory

VA Capital Asset Inventory (CAI) is the VA’s official source of real property data. The chief engineer at each VAMC is responsible for updating and certifying the data annually. The database contains building-specific information such as when it was built, renovations, number of floors, and facility condition assessments, and it has gross and departmental square foot information. The CAI data form the basis for much of the service and infrastructure gaps used in the Strategic Capital Investment Planning (SCIP) process (Broskey, 2018). CAI data are also reported to stakeholders including VA senior management, the Federal Real Property Council, the Office of Management and Budget, the Department of Energy, the Government Accountability Office, the General Services Administration, and Congress (Broskey, 2018).

Facility Condition Assessments

Facility condition assessments (FCAs) are national managed contracted studies of all VHA facilities that assess the physical condition of the buildings and the systems therein. The FCA considers life expectancy, how well the equipment or system or building has been maintained, and code compliance. FCAs are done on a 3-year construction and facilities management (CFM) coordinated cycle. Assessments occur at the building, system, and subsystem level (e.g., an emergency generator) (Broskey, 2018).

The assessment operates on an A-F scale and provides a short narrative description of any deficiencies, plus correction costs and replacement cost. Funded projects are entered into the CAI and linked to FCA deficiencies. The database is expected to be updated by local engineers when projects are accomplished to correct deficiencies.

Capital Resource Survey

The Capital Resource Survey (CAPRES) is an annual survey that the chief engineers complete through a computerized database system for each VAMC or the health-care system. The survey comprises Facilities Engineering, the full-time equivalent employee (FTEE) costs, materials costs, contract costs, building square footage, acres of land, and related information. CAPRES is meant to be used primarily by the chief engineer and the associate director to benchmark their Facilities Engineering programs against other similar programs in VHA, normally by clinical complexity index or square footage (Reed, 2019).

Much of the database is now prepopulated from other VHA databases, and there are numerous ways data can be grouped and reported. Required fields have changed over time, but the information contained in the database as of fiscal year (FY) 2017 includes the following (Reed, 2019):

• Basic information—facility contact information, complexity level, total medical center FTEE, outpatient visits, and medical center expenditures.
• Facility square footage—owned gross, leased gross, and out-leased and vacant space.
• Owned building square footage by age—less than 10 years old, 10 to 50 years old, or older than 50 years.
• Capital costs—obligations that particular year for major construction (more than $10 million), minor construction (less than $10 million), CSI (high profile clinical nonrecurring projects), and NRM (repair existing infrastructure).
• Construction and lease cost information.
• Facility condition assessment (FCA)—only for scores D and F for outstanding costs to correct deficiencies.
• Funds spent on facility FCA corrections made during the survey year.
• FTEE and labor costs broken out by Facilities Engineering section.

• Expenditures for in-house engineering labor.
• Expenditures for engineering materials, services, and one-time contracts.

Data quality is essential. CAPRES data quality is impacted by lack of clear definitions, particularly with data entered into “Engineering Administration” (Reed, 2019). Additionally, data beyond Engineering Administration are checked during initial review by the committee of the CAPRES data at the individual VAMC level. In the committee’s judgment, 5 to 10 percent of the data was missing or flawed and could not be included in any analytic review.

Work Order Tracking Database

Not only is an organizational structure required, but also a technical framework is needed to help ensure that the necessary functions are performed in a timely manner. For Facilities Engineering operations and maintenance, work assignments are typically controlled by work orders. These are assigned to individual staff members for execution. They may be initiated by either nonengineering staff to cover problems seen in the buildings or by engineering staff noticing such problems on their regular rounds. There are also work orders generated by routine maintenance, such as preventative maintenance of scheduled work on equipment. The VA is moving toward a proprietary system for generating and controlling work orders, known as MAXIMO, modified to VA hospital needs (NASEM, 2019b). The older system known as AEMS/MERS was based on the MUMPS database program and is still in use in most parts of the organization (NASEM, 2019b). There have been complications with interfacing the new MAXIMO system with various other logistics and finance systems, so the implementation of MAXIMO is still in transition. Those facilities using the AEMS/MERS system have the ability to enter equipment and systems, schedule and track preventive maintenance, accept and schedule work orders electronically, record time and material for completed work orders, and perform other basic database functions. While the AEMS/MERS database system can provide basic database support, it does not provide the features and data analysis capability of the modern work order systems.

Industry uses work order databases as a key item in understanding the needs of a facility and sets policies on how to enter the data to ensure that there is data consistency. It was noted in several discussions with chief engineers from VHA that data entry of the current AEMS/MERS and MAXIMO was not required and in some cases data were not entered due to lack of staffing (NASEM, 2019b,d,f). Some of the non-VHA speakers noted that policies on data entry had been set in their organizations, although no VHA-wide policy on data entry appeared to be in force.

Project Tracking Report

The Project Tracking Report database tracks the status of projects from the initial design phase through construction completion and activation. Specific items that represent performance include actual cost versus budget and actual time versus initial approved time. The data are updated monthly, with explanations required for variations from the plan.

Finance Report

The VA tracks financial information in great detail. Data are available through the Fiscal Service, which provides all costs and staff by specific cost codes. These data inputs are typically used as part of the VA CAPRES report discussed earlier. Some inconsistencies can occur if the staff is coded into the wrong department per VA standards. For example, if maintenance staff are put in the Office of the Chief, they will not show up in the Maintenance Section. Also, the staff may perform multiple functions such as maintenance, small projects, and so on, but staff is typically coded as one function. Cost transfers can separate this work into its constituent parts, but this is not typically done.

Strategic Capital Investment Planning Process—Capital Program

One database covers specifically the proposals for, and progress on, capital projects. As such, it is a work planning and execution document rather than an inventory. Decisions between competing projects at the VISN and medical center levels are made using SCIP. The 10-year capital investment plans included in SCIP will normally come out during the first quarter of a given FY. SCIP action plans will normally be due around January or February of a given FY. There are four primary components to the SCIP process, which largely reflect the steps or phases in the section “Planning and Programming” in Chapter 2 (Broskey, 2018):

1. Gap analysis. A gap analysis will be conducted for gaps identified at the department level, such as access, workload, space, condition, and energy.
2. Strategic capital assessment. Based on the gap analysis, this narrative document explains how gaps will be reduced, why certain investments were chosen, and how capital investments were prioritized. Strategic capital assessments are developed for each facility, where appropriate, and rolled up to the VISN level. The strategic capital assessment also considers noncapital solutions for gaps where appropriate.
3. 10-year action plan. This plan is developed for each facility and provides more detail than the strategic capital assessment. Depending on the asset category, specific medical center and regional-level investments are listed for 3, 5, or 10 years to reduce gaps with lump sums for the remaining years. This applies to new rather than existing investments. For the remaining years, the plan lays out more general resource requirements. Action plan components include major and minor construction, leases, NRM projects, sharing, enhanced-use leasing, and disposals. All action plan initiatives must address gaps identified in the gap analysis. The latest action plan guidance provides specifics on the action plan requirements for any given FY.
4. Business case application. Once the SCIP action plan is approved, capital investments that are both identified in the 10-year action plan and meet established thresholds need to have a business case application completed for the next budget year cycle submission. Business case applications are prioritized against a department-wide set of criteria for the development of the budget process. A separate call for business case applications is issued, with details on the current cycle requirements. A call for business case applications generally appears around March, with applications due in May of a given FY.

TASKS PERFORMED BY VHA FACILITIES MANAGEMENT (ENGINEERING)

While the inventory of buildings, systems, and other assets helps define the scope of any staffing model, such a model also needs to know what tasks need to be performed on and for these facilities. Thus, we have to examine what functions/tasks come under the domain of Facilities Engineering before we can proceed to consider staffing models and ultimately provide a road map to develop a valid model for Facilities Engineering. This section provides a listing of the main tasks of Facilities Engineering within the three core categories introduced in Chapter 2.

1. Engineering Administration. This oversees all of the categories as well as providing financial, human resources, and planning functions.
2. Capital Program. Planning, design, construction, and activation of construction projects. This includes leasing and all real estate activities.
3. Operations and Maintenance

   3.1 Operations. Includes high-pressure boiler plant, chiller plant, and other utility plants.

   3.2 Building maintenance. Includes skilled trades, e.g., HVAC, electrical, plumbing/pipefitting, carpentry, painting, HVAC controls, and general mechanics, and can also include work contracted out such as elevator maintenance.

4. Grounds maintenance for the medical center. This may be included under Operations and Maintenance or directly under Engineering Administration.

5. Vehicle operations. This may be included under Operations and Maintenance or directly under Engineering Administration.
6. Biomedical Engineering. Involves selection, maintenance, repair, and staff training for all medical equipment.
7. Safety. Includes general safety and fire safety, environmental compliance (Environmental Protection Agency [EPA]), and industrial hygiene program.

It was noted that the last two functions, Biomedical Engineering and Safety, are not in the scope of this committee’s report. Both of these functions have already had a model designed for them (Broskey, 2018). It was also noted that custodial services were not included in the committee’s discussion.

Additional functions requiring Facilities Engineering time and resources are the various external audits and standards that VHA has agreed to meet, and various special VHA directives known collectively as “Above and Beyond” (Broskey, 2018). These are a sample of many other directives and federal laws that apply to VHA Engineering. All of these are complied with using established procedures and internal audits. External audits include those by the Office of the Inspector General, The Joint Commission, Occupational Safety and Health Administration, the EPA, the Nuclear Regulatory Commission, the Veterans Administration Central Office, and VISNs. The “Above and Beyond” list comprises the Energy and Water Management Program, Fleet Management, the Cultural Resource Management Program, Physical Security Requirements, Contracting Requirements, Boiler Plant Operations, Legionella Control, Sterile Processing Services, Women’s Health, Safety and Health During Construction, Electrical Power Distribution Systems, and Support for the Department of Defense (Broskey, 2018; NASEM, 2019d).

Each of the functions that Facilities Engineering is tasked with can vary considerably in complexity between VMAC and within them—for example, by the time of year and presence of capital projects on site. Also, each function requires appropriately skilled and credentialed people to perform that function, and a managerial organization to coordinate and control the activities. Typically, the managerial structure is headed by a degreed engineer, known as the chief engineer, with appropriate staff and deputies dependent upon the size of the workforce, and ultimately on the size of the facilities managed. Based on an OCAMES review of approximately 50 to 60 VA medical center organizational charts for engineering, model organizational charts were drafted that include best practices. The sponsor indicated that these were not definitive, but they do illustrate the typical types of positions and configurations and reporting lines that are found in the VA medical centers. These model organization charts apply to various levels of medical center facility size and facility complexity, and these will also inform and decisions on staffing levels and models. Note that some VAMCs have unique functions such as running an onsite fire department or a wastewater treatment facility.

CONTEXT IN WHICH THE VHA ENGINEERING STAFFING REQUIREMENTS OPERATE

The VHA Engineering Staffing Model requirements operates within a context, and the committee heard about many ways in which the context is changing and will continue to change in the coming years (NASEM, 2019d). Any staffing model must incorporate parameters and thresholds that can be adjusted when the context in which they operate change substantially. Parameters such as building square footage may remain relatively stable over time, but parameters such as the size of the veteran population served, the age and gender characteristics of the veteran population, or the types of services provided at a given facility may change dramatically. Some of these changes may dramatically impact VHA Facilities Management (Engineering) workload, while others may have relatively little impact.

Changing Veteran Population

According to information available on the VA website,³ the Veteran Population Projection Model 2016 (VetPop2016) provides the latest official veteran population projection from the VA. The eligible veteran population

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³ See https://www.va.gov/vetdata/Veteran_Population.asp.

is expected to steadily decline from 20.0 million in 2017 to roughly 13.6 million by 2037 (VetPop2016). It is also critical to acknowledge that currently, only about 9 million veterans are eligible for VA health care. At the same time, while the number of male veterans is expected to decline by roughly 2.3 percent annually between 2017 and 2037, the number of female veterans is expected to grow by about 0.7 percent annually, or from roughly 1.9 million in 2016 to 2.2 million by 2047, reaching 9 percent of all veterans in 2016, and more than 18 percent by 2045 (Hansen, 2017). The veteran population, like the U.S. population in general, is aging and subject to an increasing burden of (usually) multiple chronic diseases, frailty, musculoskeletal disorders, and associated limitations in mobility, vision, hearing and other functional capacities (NASEM, 2019d).

VHA is adapting to changing demographics, including the higher percentage of female veterans, by repurposing existing buildings or constructing new facilities focused on changing health-care needs. For example, OB-GYN clinics and female-centered treatment programs, infertility treatments, traumatic brain injury services (VA, 2018), and other requirements are driven by changes in military accession and retention policies, and a wider array of religious beliefs and practices, sexual preferences, and gender identity in the veteran population. The increasing diversity of the veteran population may have direct and indirect impacts Facilities Management (Engineering) workload. For example, the committee heard during its meeting about special considerations when performing maintenance work in a clinic or an inpatient ward that is dedicated to the treatment of female victims of rape or domestic violence, particularly if the maintenance workforce at the site is primarily (or entirely) male. Historically, this would not have been something that Facilities Management (Engineering) departments needed to consider when planning maintenance work.

Changing Geographic Distribution of the Veteran Population

In addition to the overall decline in the number of veterans over the next 30 years, there has been an exodus from much of the Northeast, the former rust belt states, and California. There has been slight growth in several states in the southeastern United States, along with areas of Texas, Arizona, Wyoming, Kansas, eastern Washington, and eastern Colorado.⁴ In 2017, 50 percent of all veterans lived in 10 states (California, Texas, Florida, Pennsylvania, New York, Ohio, North Carolina, Virginia, Georgia, and Illinois). According to the same VA website,⁵ by 2037, Washington will replace Illinois in the list of 10 states likely to have the most veterans, and Pennsylvania and New York will drop much lower in the rank order. This shift in geographic distribution could lead to a larger Facilities Management (Engineering) workload at VAMCs in the areas with an increasing veteran population—to the extent that the VA increases the number or size of facilities where veterans receive care. For states losing veteran population, there may be changes or reductions in the types of clinical services provided at existing facilities, and some facilities may no longer be used, which could reduce Facilities Management (Engineering) workload. However, multiple speakers told the committee that it is important to keep in mind that even unused buildings must still be maintained, so Facilities Management (Engineering) workload in areas with declining veteran populations may not decline at the same rate as the workload for other departments (e.g., nursing).

Changing Veteran Patient Needs

In 2016, the number of Gulf War–era veterans surpassed the number of Vietnam War–era veterans. In 2017, there were 7.27 million Gulf War veterans (Iraq/Afghanistan). There were also more than 6.65 million Vietnam War-era veterans, more than 1.47 million Korean War-era veterans, and an additional 624,000 World War II–era veterans.⁶ A higher percentage of veterans than in the past have experienced multiple combat tours of duty. This changing demographic of scale and lethality of conflicts, plus the growing percentage of female veterans, has changed the medical needs of the veteran population (i.e., more mental health requirements, more OB-GYN

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⁴ See https://www.va.gov/vetdataby 2037, specifically, the National Center for Veterans Analysis and Statistics, VA Veteran Population Projection Model 2016.

⁵ See https://www.va.gov/vetdataby 2037.

⁶ National Center for Veterans Analysis and Statistics, VA Veteran Population Projection Model 2016, https://www.va.gov/vetdata.

including in-vitro fertilization for veterans with service-connected disabilities, more primary care, more poly-pharmacy, spinal cord injury care, more traumatic brain injury care, more homeless patients, etc.). According to the VHA FY 2017 Annual Report, veteran homelessness has been reduced by 50 percent and VHA continues to ramp up efforts to confront the opioid crisis (VA, 2018).

It is hard to predict how these changes may impact the workload for Facilities Management (Engineering) staff. In locations where these changes lead to a higher proportion of critical care facilities or facilities that provide more clinically complex medical services than in the past, the workload for Facilities Management (Engineering) is likely to grow. Similarly, if VHA provides more long-term patient care facilities than in the past, then the workload for Facilities Management (Engineering) will likely grow—but possibly only if there is no concomitant decrease in the provision of other clinical services at the same location.

Veteran Choice Program and the MISSION Act

With the declining and changing veteran population, and the general shift away from the densely populated Northeast for the more sparsely populated areas of the United States, timely access to the available VHA facilities has become challenging for more veterans. To address this challenge, VHA established roughly 800 community-based outpatient clinics. However, even with VHA providing (in FY 2017) 109 million outpatient visits, 615,000 medical/surgical inpatients, 149,000 mental health inpatients, and 118,000 institutional/long-term inpatients, the system has struggled to meet the needs of all eligible veterans, often related to facility availability and drive-time. Therefore, VHA also established the Veterans Choice Program (VCP), which allows veterans to seek care from civilian providers when they cannot gain timely access to VHA services. The VCP has provided access to care for 1.8 million veterans who received nearly 50 million appointments with civilian providers (VA, 2018).

The MISSION Act, passed in June of 2018, is intended to further enhance, expand, and streamline veteran access to health-care services. It strengthens and consolidates payment for community-based services, offers a greater array of service options, such as walk-in and telehealth services, and includes additional support for opioid treatment programs and caregiver support.⁷ It is difficult to predict exactly how the MISSION Act will affect VHA Facilities Management (Engineering) workload, as the workload will continue to depend on the amount of space that must be maintained, the existing condition of that space, and the type of services offered in that space.

Maintaining Facilities, Unless or Until They Are Decommissioned

As the predicted veteran population steadily declines from 20 million to 12 million over the next 30 years, coupled with the fact that less than half of veterans are eligible for VA medical benefits and the impacts of the VCP, the committee assumes that there will be a continued effort to reduce the VHA facilities’ footprint. This will not be a quick or easy process. As of June 21, 2017, the VA lists more than 1,100 outdated, underutilized, or vacant buildings. The department began the process of disposing or reselling 142 buildings. They also report 430 vacant, or nearly empty, buildings that are more than 60 years old, which cost about $7 million to maintain. Facility consolidation was one of the 13 areas of improvement identified by (then) Secretary Shulkin (Ogrysko, 2017). Disposing of federal facilities through sale, transfer, or demolition is difficult due to a multitude of regulations and laws that govern the process. Many stakeholders can stake a claim to a federal property once it is declared “excess” and listed for sale or transfer, including Native American groups and homeless advocates. There are many environmental considerations and potential studies and reports that are required prior to disposal. Additionally, before disposal can be made, the VA must assess the property for its eligibility for historic designation or registration on the Historic Register. If a facility is designated historic, disposal actions are even more complicated and costly. It is also often difficult to find a buyer or tenant for underutilized or excess facilities that are within a federal campus, which is sometimes the case with VHA facilities. Clearly, the implication for Facilities Management (Engineering) is that none of these buildings can be completely ignored from a maintenance perspective. At a minimum, unused buildings must be maintained sufficiently that they do not become a safety hazard or foster

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⁷ See https://www.va.gov.

negative public perceptions about VHA’s ability to maintain facilities in a reasonable manner. For historic buildings, the maintenance requirements involve more than just minimal upkeep.

Advances in Facility Management Technology

The committee heard about technology, such as the Internet of Things, in which equipment or systems can self-diagnose when they are in need of maintenance and initiate a work order in a centralized work order tracking system, or allowing the equipment/system to be monitored from a remote location. Both capabilities may reduce workload for Facilities Management (Engineering) by allowing for more efficiencies in maintenance planning or reduced travel time. The committee also heard about “digital bots” that can process questions and requests posed in natural language form (NASEM, 2019e). In a Facilities Management context, digital bots might be able to answer a variety of questions that, currently, require an in-person response from a Facilities Management (Engineering) staff member. A similar application could direct a question to the most appropriate (e.g., plumber, electrician, or HVAC technician) and currently available staff member. Increasingly, organizations are using mapping and routing tools to identify the most efficient sequencing of events or travel between points. In the Facilities Management (Engineering) context, this could mean optimized service call routing within or across VAMC campuses. While advances in technology can reduce workload in some ways, several presenters noted that advances in technology can also lead to new requirements and skills sets. For example, a health-care organization may purchase an advanced automated system or piece of equipment without carefully considering that someone must be able to install and maintain it (NASEM, 2019b). As a second example, automated systems may require time to monitor and interpret data coming out of the systems, and sophisticated troubleshooting when a technologically advanced system malfunctions.

Trends in Medical Services

As noted in the interim report (NASEM, 2019d), VHA, like all other medical service providers, is leading, experiencing, and adopting trends in medical services such as providing more and more services in an outpatient center, focusing more on preventive care, which is enabled by new and improved diagnostic and therapeutic technologies, greater coordination of care across providers, and increased focus on measuring patient outcomes as opposed to amount and type of care provided. Trends in medical services will likely have mixed impacts on Facilities Management (Engineering) workload. There may be a reduction in the number or size of in-patient wards to be maintained at a given facility, but an increase in the number of surgical suites to be maintained at an affiliated outpatient clinic. There may be more workload to convert existing space to support new medical service purposes or less workload to maintain facilities that are no longer needed.

Other Requirements That Benefit the Nation in General

VHA is the single largest provider of physician graduate medical education (clinical residencies post-medical school) in the nation and is also a major contributor to medical and scientific research. Roughly 69,000 physicians at all levels, including medical students, medical (physician) residents, and fellows are trained in VHA facilities each year (CRS, 2018). From the perspective of Facilities Management (Engineering), must also maintain research laboratories, some of which require extensive measures that fall within the purview of Facilities Management (Engineering) such as airlocks, handling hazardous waste, and ensuring highly regulated environmental conditions for the care of research animals. Additionally, there are some kinds of VA-eligible patients who have sustained horrific injuries, including serious mental trauma, where VHA is the only viable alternative, as the traditional health-care market would be seriously challenged financially to care for long-term patients with little ability to pay. For Facilities Management (Engineering), this could mean more long-term facilities with advanced life support equipment to be maintained.

VHA is also a component of the National Disaster Medical System (NDMS)—a federally coordinated initiative that augments the nation’s emergency medical response capability. The four federal partners in NDMS are

the Department of Health and Human Services (U.S. Public Health Service), Federal Emergency Management Agency, Department of Defense, and Department of Veterans Affairs. The overall purpose of NDMS is to establish a single national medical response capability for assisting state and local authorities in dealing with the medical and public health effects of major peacetime disasters; and providing support to the military medical system in caring for casualties resulting from overseas armed conflicts.⁸ Facilities Management (Engineering) must keep designated facilities sufficiently operable to maintain this level of preparedness.

SUMMARY

Currently, VHA does not have a staffing model for its facility workforce, and each location defines how many workers are needed to fulfill its commitment to providing ongoing quality of care. The Federal Property Management Reform Act of 2016 requires federal agencies 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. Such a model can be used at various levels of aggregation—specifically at the overall (national) VHA, at the VISN, and at VMAC.

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⁸ See https://www.va.gov/vhaemergencymanagement/cemp/cemp_ndms.asp.

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