Summary

The Committee on Facilities Staffing Requirements for Veterans Health Administration was established as part of a project to prepare a comprehensive resource planning and staffing methodology guidebook for the Facilities Management (Engineering) Programs of the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA). To collect pertinent data, the committee held five committee meetings and five workshops. From these activities, the committee has developed both a deep appreciation of the complexities associated with VHA Facilities Management (Engineering) and an understanding of its current methods of staff modeling and planning. The wide-ranging expertise brought to bear on the study challenge, through the varying committee investigations, has allowed the committee to evaluate existing models for potential analogues of the VHA Facilities Management (Engineering) staffing situation. In addition, through the many interactions with VHA staff, Veterans Integrated Services Network (VISN) leadership, and center experts (as well as a site visit to the VHA Portland, Oregon, Veterans Administration Medical Center [VAMC]), the committee developed a deep respect for the commitment of VHA to the service of our veteran community. The committee’s effort in developing a staffing methodology for engineering and facilities is designed to provide an enhancement to their already noble work.

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 Facilities Management (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 VISN, and at VMAC.

The committee spent considerable effort understanding major organizational functions and responsibilities of a general facilities management (FM) organization—to include the scope of duties and responsibilities, staffing, and skill sets—to execute and deliver on these duties and responsibilities. This effort consisted of an in-depth analysis of capital programs (planning and programming), project management and delivery, and operations and maintenance (O&M). In addition, the committee acknowledged the complications of other FM functions—for example, real estate management, landscaping, vehicle management, and environmental compliance—that impact an organization’s success. This effort included a review of engineering administration core competencies and an assessment of the enhancement of FM functions through the application of state-of-the-art technologies. The committee also studied a range of performance measures to monitor and assess the efficiency and effectiveness

of these functions. Last, in the review of the FM function, the committee assessed the additional considerations of federal versus private sector facilities and the difference in nature of the management of health care facilities.

The committee found task lists for the three main functions of Facilities Management (Engineering) are O&M; Capital Projects project management and project delivery; and Engineering Administration. Note that typical VHA engineering departments consist of engineering administration, project management, maintenance skilled trades, grounds maintenance, operation of high-pressure steam, operation of chiller plants, biomedical engineering, and safety (including overall medical center safety, fire safety, emergency management, industrial hygiene, and Environmental Protection Agency [EPA] compliance). In some facilities, there may be additional maintenance activities required for the research laboratory and medical equipment. Maintenance can also include regular sustainment and restoration projects—such as air handling replacements, an overhaul of patient areas, or comprehensive relamping—for which planning and oversight may be different than larger capital projects. Since staffing models already exist for the safety program and biomedical engineering, these are not included here except as they impact the other functions such as engineering administration (NASEM, 2019d).

This aspect of the study also focused on FM as it applies to VHA by delineating the complexity of the VHA Facilities Management (Engineering) function in terms of the medical activities at each site and the great variety of buildings and systems across a site and the whole enterprise. The committee first noted the complexity of VHA’s challenge. VHA is the largest of the three administrations that comprise the VA, which continues to meet veterans’ changing medical, surgical, and quality of life needs. In addition, VHA provides training for a majority of U.S. medical, nursing, and allied health professionals, with about 60 percent of all medical residents obtaining a portion of their training at VA hospitals (Broskey, 2018).

VHA supports a unique, often highly complex, patient population. Many aspects related to day-to-day VHA health care delivery appear similar to those found at commercial hospitals, providers, and health care facilities. However, there are important key differences between the commercial sector and VHA that drive policy, staffing, and facilities requirements rarely faced by the commercial sector. These differences include patient populations with homelessness, post-traumatic stress disorder, suicidal intentions, prescription drug dependency issues, and domiciling needs that are often expensive and time intensive. Additional differences involve significant divergence from the commercial sector by requirements to run water treatment plants, fire stations, boiler plants, or snow removal capability. Many VAMCs possess major grounds acreage to be maintained and historic buildings that are protected by statutes from destruction. Most commercial health care facilities have no similar demands.

The VA is one of the largest federal property-holding agencies, with more than 33,000 acres of land and more than 5,500 buildings. VHA is, according to its website, “America’s largest integrated health care system, providing care at 1,243 health care facilities, including 172 medical centers and 1,063 outpatient sites of care of varying complexity, serving 9 million enrolled veterans each year”¹ (NASEM, 2019d,e). In addition, VHA has opened outpatient clinics and established telemedicine and other services to accommodate a diverse veteran population and continues to cultivate ongoing medical research and innovation (NASEM, 2019d). Beyond these facilities, the Veterans’ Choice Plan has opened non-VHA facilities to veterans.

Facilities specific to VHA fulfill clinical, operational (i.e., physical plants), research laboratory, and administrative functions. Each site is designed to serve a geographical location with specific health care needs. VHA’s building inventory has sites of different ages, and often there is a mix of building size and age at each site or campus. The buildings themselves contain a variety of functions with extremely different space and infrastructure demands. The complexity includes such factors as operating rooms, outpatient facilities, spinal cord injury centers, domiciliary or other long-term skilled nursing facilities, and orthopedic treatment areas. They also have differing needs for utilities and contain different equipment, both building services and biomedical systems. Each site has a chief engineer (a degreed position) with a staff of engineers, tradespeople, and administrators to ensure that the facilities remain operable and meet all requirements for medical staff and patients. Sites differ in the current number of staff in Facilities Management (Engineering), even for sites that appear comparable in size, complexity, and age.

The committee also observed that VHA does not lack for data, although VHA falls short in translating multiple databases into actionable information for each echelon of management. As an aid to resource allocation, VHA has

___________________

¹ As of April 2019.

developed a Facility Complexity Model that calculates a level for each medical center to provide peer grouping of facilities based on clinical complexity. The VHA Facility Complexity Model brings together many variables—for example, patient population, clinical services complexity, and education and research. The Facility Complexity Model, along with the number of patient visits, provides the primary data for funding the various VAMCs. While the model does reflect clinical complexity, it does not reflect the complexity of infrastructure at individual VAMCs, although the index is potentially pertinent to a staffing model.

As in any organization, VHA keeps track of its buildings, systems, and other capital assets using a variety of databases and measures. These include the VA Site Tracking Database (VAST), the Capital Asset Inventory (CAI), Facility Condition Assessments (FCA), and the Strategic Capital Investment Planning (SCIP) database. VHA also has considerable data available in resources such as the annual Capital Resource Survey (CAPRES) owned by the Office of Capital Asset Management, Engineering, and Support (OCAMES) and the portfolio of variables available in a database maintained by the VA Office of Productivity, Efficiency, and Staffing (OPES) to help inform any staffing and resource plan or model. It also has, although in separate databases, measures of performance, The Joint Commission outcomes, plus internal measures such as a fraction of preventive maintenance actions completed on time, frequency of adverse incidents, or the results of satisfaction surveys of staff and patients.

INTERIM REPORT

The committee heard consistent comments about a general lack of accuracy in the input of base-level data into existing engineering data systems. Accurate data regarding the functional and physical characteristics of VA facilities is required in order to implement a staffing model for Facilities Management (Engineering). The committee wrote an interim report that was delivered to the sponsor in August 2019 (NASEM, 2019d). The committee’s recommendations in that report were to establish policies, procedures, and training to ensure timely and accurate data were entered into the multiple systems, including work orders. In addition, VHA should carefully consider the evolution of a data management system that allows for the merging of data from the various data systems to allow for accurate, transparent, and timely decision-quality information at each echelon of management within VHA (NASEM, 2019d).

RECOMMENDATION 1: The Veterans Health Administration should ensure that the choice of platform of facilities database is given careful consideration to ensure continual completeness, accuracy, reliability, and validity of the data. (Interim Report)

RECOMMENDATION 2: Policies, procedures, and training for entering and updating information for any comprehensive database, such as the Capital Resource Survey (CAPRES), and work order data should be implemented by the Veterans Health Administration to support staffing and management models. (Interim Report)

DATA GATHERING

Overall, the workshops and meetings showed a growing trend in integrating data systems in the facilities world, to include an increasing number of tools that support integration. Where integration has been successful, there has been a reduced burden on the facility workforce for data entry.

To introduce the concept of modeling, the committee heard from workforce planning experts, including the U.S. Army, the National Aeronautics and Space Administration, and the National Institutes of Health; private-sector health care organizations; and private-sector property management organizations. Models were presented from the U.S. Air Force and APPA (formerly the Association of Physical Plant Administrators), both of which apply to maintenance systems with their inherent mix of deterministic and stochastic modeling approaches for determining staffing requirements. In addition, several entities within the VA have staffing models developed or currently being developed; these include Interior Design Staffing, Nursing, Occupational Safety and Health, Logistics, and OPES. There is no shortage of models linked to Facilities Management (Engineering) that reflect either or both

the nature of the functions (e.g., Federal Aviation Administration [FAA] systems specialists) and the VHA environment (interior design, etc.). There are also more general classifications of staffing models—that is, those based on a statistical analysis of current staffing levels and those based on the summation of task frequency and duration.

After a careful review of the basic characteristics of models in general (and staffing models in particular), this report provides a general checklist of features to evaluate when choosing among staffing models: transparency, scalability, usability, relevance, validity, adaptability, utility, communicability and validation, and verification capability. The committee examined the two ways to derive staffing models (extrapolating from status quo or by preparing a task-based staff structure) and concluded that extrapolation could be done based on current staffing using the variance among sites to fit statistical models to the staffing data.

Performance measures were a key area of concentration, owing to the fact that in a function where required tasks and their durations are not always predictable, it is important to understand relevant performance measures so that outcomes for different staffing levels can be predicted with accuracy. In addition, this requires leadership to assess the risk associated with maintenance engineering as it applies to patient outcomes. The committee addressed input, process, and outcome measures. Input measures tell the enterprise what is available to accomplish its mission (number and/or size of facilities, numbers of patients, systems, etc.). Process measures, also known as intermediate or internal measures, describe the internal workings of the enterprise. These include the use of overtime, use of contracts, and duty demands, among other measures. Outcome measures are the ones that really matter to the mission. These are measures of clinical success for patients—for example, impacts on patient access, mortality and morbidity, preventable readmissions, and patient satisfaction with their VAMC experiences. The committee concluded that the best attribute of the staffing model was to reflect the impact of engineering and facilities management on a mission, and in the case of VHA, that mission is centered around patient outcomes.

The committee provided a vision for the VHA Facilities Management (Engineering) Staffing Model. First, it examined task lists for the three main functions of O&M; capital projects project management, and project delivery; and engineering administration. The methodology provides a workload-based foundation for establishing and justifying VHA Facilities Management (Engineering) staffing requests, just as VHA Nursing has a staffing model based on patient care needs that translates into the number of nurses required at any given VAMC. Other organizations have developed standard times for tasks for their activities across sites, so this could be applied to VHA Facilities Management (Engineering) where similarities exist. Helpful software is available for organizing such data by building and across sites.

A perfect staffing model would strike a balance between the specificity of predictions and cost/time of obtaining and validating the necessary data. The dimensions along which VAMC sites vary are key to model development. Site size, traditionally measured by square feet of used building space, is clearly an important first consideration, but alone it cannot capture all of the information necessary to predict staffing. Clinical complexity, as measured by the VHA Facility Complexity Model, reflects the types of procedures carried out at a site, the patient volume, and several other factors that appear to affect staffing levels. Age and condition of buildings and systems within them are other relevant considerations, as are considerations for mandated use of VHA facilities in response to local and regional emergencies. The presence of special activities such as a fire department and the specific requirements for continuous staffing of boiler rooms (mandated in some jurisdictions) are also staffing dependent.

Many more measures are needed for a comprehensive picture of engineering effectiveness. Obvious examples are the patient outcome measures, but also patients’ reported experiences and satisfaction. Such data are already collected by VHA—for example, measures such as the fraction of time that a patient or member of medical staff is unable to be serviced because of engineering system nonavailability. To begin this process for VHA, this report provides a hierarchical listing of the main tasks of Facilities Management (Engineering).

Clearly, a staffing model must take into account some subset of these variables to be logically and statistically valid, but the issue is one of how many are actually needed. In practical terms, the issue may be one of how few variables are needed to build a model of sufficient reliability and validity for use by administrators at all levels of aggregation.

Although the committee was not specifically tasked with examining the effect of ongoing and future changes in the mission and environment of VHA, modelers and users of models do need to be aware of how these changes will affect staffing. From the standpoint of facility maintenance, trends in medical services, policy changes, as

well as the location of the veterans become drivers for the model. The model must consider a declining veteran population, a demographic shift in veterans’ residences, the impact and cost of the VA Choice initiative,² changing medical trends, availability of skill sets, and evolving technologies. These future changes and directions may require the addition of a new predictor variable to any staffing models.

Any database for use by a staffing model needs to include the elements pertinent to staffing levels. This means that it needs to go beyond just details of buildings at each medical facility, although these details are of course fundamental. For example, measures of performance relevant to Facilities Management (Engineering) are needed so that staffing models can be related to outcomes as well as to facilities inputs. The current annual CAPRES contains building and site information and also current staffing levels and contract details and is one possible approach to acquiring some of the data necessary for modeling. The committee provided an extensive list of potential data sources compiled from various workshops and meetings. Much of the data from those sources already exists to a varying degree of accuracy but is not integrated into a single trusted data set.

RECOMMENDATIONS

The committee has made several findings and recommendations in the report chapters and has chosen to highlight the key ones during the rest of this summary. The numbering of the recommendations is where they fall in the report.

As a starting point, the committee developed a VHA Facilities Management (Engineering) Staffing Methodology framework. This notional application of the VHA Facilities Management (Engineering) Staffing Methodology identifies baseline staffing elements common across all VAMCs followed by infrastructure complexity parameters that the committee believes substantially impact workload for one or more Facilities Management (Engineering) functions and that vary across VAMCs. These staffing elements can be either a government employee or a contractor.

RECOMMENDATION 4.5: The Veterans Health Administration (VHA) should establish baseline VHA Facilities Management (Engineering) staffing levels common to all Veterans Administration Medical Centers by function (Engineering Administration, Capital Projects, and Operations and Maintenance) and job (e.g., project engineer, maintenance foreperson, skilled trades). This baseline model should take into account all mandatory positions and roles dictated by VHA policy and other federal directives, or Joint Commission standards.

After a staffing baseline is established, the VHA Facilities Management (Engineering) Staffing Model should be supplemented with parameters that impact engineering workload significantly and that vary across VAMCs. The committee identified 27 parameters, although the staffing model could, and probably should, include a much smaller subset and still produce accurate staffing estimates. The parameters include such considerations as building gross square feet and usage, managed acres, space utilization intensity, building age and condition, number of buildings, types of buildings, buildings on the historical register, and climate zone. While the committee believes that it is necessary to develop a VHA Facilities Management (Engineering) Staffing Model based on a shared understanding of the desired level of performance for different functions, it could not find evidence that such performance levels have been defined across all VAMCs, beyond those that define requirements for specific systems or processes, or perhaps the implied goal of “achieving or surpassing Joint Commission standards.” A recent Government Accountability Office report reached a similar conclusion:

___________________

² Veterans Choice Program (VCP) allows veterans to seek care from civilian providers when they cannot gain timely access to VHA services. For more details https://www.va.gov/communitycare/programs/veterans/VCP/index.asp, accessed October 2019.

RECOMMENDATION 4.1: The Veterans Health Administration (VHA) should establish and define desired performance levels for VHA Facilities Management (Engineering) that flow from the organization’s mission or policy and that can be used to drive more specific performance goals, objectives, and performance measures for Facilities Management (Engineering).

The committee was informed of numerous areas of Facilities Management (Engineering), particularly work order management, that did not have in-place published polices. The committee observed the absence of clear guidance that contributes to the perception of inconsistency of data input across the enterprise.

RECOMMENDATION 4.2: The Veterans Health Administration should establish comprehensive minimum performance levels for all areas of Facilities Management (Engineering) beyond the limited policy currently available.

The methodology will rely heavily on expert judgments to start, with decision support from analyses for which high-quality data are already available—for example, examining which infrastructure parameters are most strongly related to current Facilities Management (Engineering) staffing levels. As the methodology input and outputs are reviewed and adjusted over time, decision support based on empirical links between staffing levels and performance will likely increasingly play a prominent role.

RECOMMENDATION 4.3. To the extent possible given the availability of high-quality data, the Veterans Health Administration should use analytic techniques to empirically examine the links between input variables related to Facilities Management (Engineering) staffing levels (e.g., labor hours, labor costs, contracted services costs) and key performance indicators reflecting a shared understanding of desired levels of Facilities Management (Engineering) performance.

The committee heard that VHA Facilities Management (Engineering) has specific policies for the performance of boiler plants, electrical testing, legionella, vehicles, and energy. However, except for an expectation to meet Joint Commission standards, there are no specific requirements for heating, ventilation, and air conditioning (HVAC), plumbing beyond legionella, carpentry, painting, work order system, engineering administration, or project management. The committee recommends that VHA articulate desired performance levels that flow from the organization’s mission and that can be used to drive more specific performance goals, objectives, and measures for Facilities Management (Engineering). Further, several engineering positions and roles are mandated by VA or other federal requirements, although it is not clear how some of the roles are distributed across VAMCs within a VISN.

RECOMMENDATION 4.4: The Veterans Health Administration (VHA) should substantiate baseline, VHA Facilities Management (Engineering) staffing levels, including all mandated roles, common to all Veterans Administration Medical Centers by function (Engineering Administration, Capital Projects, and Operations and Maintenance) and job (e.g., project engineer, maintenance foreperson, skilled trades).

The committee then recommended a process for initiating, implementing, and validating the staffing model as described in the following specific recommendations. 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 applies his or her expert management judgment to the model output.

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.

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.

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.

The VHA Facilities Management (Engineering) Staffing Model should be designed to support an implementation that is transparent to all stakeholders, scalable across the spectrum of medical center sizes and missions, and based on sound logic to provide defensible staffing requirements to support a prudent investment of taxpayer dollars. Any model developed along the lines presented should also be validated by a body separate from the task force. This validation may be totally or partially external to VHA. Once developed, the model should be the starting point to defend annual budget requests and to manage facility staffing risk across medical centers based on actual funding.

Throughout this study, the committee was impressed with the judgment of Engineering 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.

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 will require VHA Headquarters leadership emphasis and support from the VISN leadership, medical center directors, chief engineers, finance, and human resources offices to adhere to the design and coordination timeline and to move through the efforts necessary to implement the staffing adjustments based on the model. Funding to implement this staffing model will require a dedicated investment that should be transparent in both the budget request and the distribution and execution of the appropriated funds.

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 Headquarters 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.

Following early implementation, the committee strongly recommends an annual review process to make adjustments as needed to fine-tune the parameters, thresholds, and staffing variances based on user feedback, and to take into account the changing conditions in which VHA operates.

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.

Last, the committee recommends that a standing body be formed of experienced chief engineers to meet on a routine basis, ideally quarterly, to share insights and help shape the facility mission to continually best support VHA strategic initiatives. They may be representatives by region or by VISN. This body would serve as a Chief Engineer Facility Advisory Council (CEFAC) and have the lead in overseeing the VHA facility staffing model annual reviews. In addition, this group would be ideally suited to review any policy questions or recommendations that emerge from the task force.

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.

VHA is on the right track to aggressively seek a new and appropriate facility workforce model. This report represents the guidebook requested in the statement of task. The success of the VHA mission to provide an effective environment of care is directly dependent on well-functioning infrastructure and operational facilities. VHA’s leadership emphasis on this priority effort is highly commendable.

This page intentionally left blank.