Review of Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic

Summary

Review of Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic, a September 2023 report of the Pandemic Response Accountability Committee, developed by its Health Care Subgroup. It states that the review covers four federal health care programs: Department of Defense Medical Treatment Facilities, Department of Justice Federal Bureau of Prisons, Department of Veterans Affairs Veterans Health Administration facilities, and Medicare- and Medicaid-certified nursing homes. The key insights state that nurses and medical officers were the most commonly reported positions with shortages, and that a limited labor pool, noncompetitive pay, COVID-19 requirements and a challenging hiring process were the most commonly reported contributing factors. Monetary incentives were the most commonly reported strategy to recruit and retain personnel.

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Review of Personnel
Shortages in Federal
Health Care Programs
During the COVID-19
Pandemic
September 2023
PANDEMIC RESPONSE
ACCOUNTABILITY COMMITTEE

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Message from the Pandemic
Response Accountability Committee
While personnel shortages existed in the health care community before the pandemic, the
pandemic exacerbated these shortages. Maintaining an appropriate level of personnel in health
care facilities is essential to providing a safe work environment for health care personnel and
quality care to patients. The Pandemic Response Accountability Committee’s (PRAC) Health Care
Subgroup developed this report to share insights into personnel shortages across four select
federal health care programs, or the providers they
reimburse (hereinafter referred to as “federal health care
programs”). Together, these four programs provide health
care services to approximately 20 million individuals.
This report provides Congress, federal and state
agencies, health care organizations, and other
policymakers with information to inform and raise
awareness on health care shortages across the four
federal health care programs. Specifically, this report
summarizes the types of personnel shortages most
commonly reported; factors that contributed to personnel
shortages; impacts most commonly encountered; and
the incentives and strategies used to recruit and retain
personnel, and minimize burnout for existing personnel
across the four federal health care programs.
OIGs identified the following key insights across the four
federal health care programs reviewed.
•	 Nurses and medical officers were the most
commonly reported positions that experienced
shortages during the pandemic.1
•	 A limited labor pool, noncompetitive pay, COVID-19 requirements, and a challenging hiring
process were the most commonly reported factors that contributed to personnel shortages.
•	 A decrease in patient access to care and patient satisfaction; and an increase in health care
personnel work hours and responsibilities were the most commonly reported impacts resulting
from personnel shortages.
•	 Monetary incentives were the most commonly reported strategy to recruit and retain
personnel.
The four Departments and facilities
reviewed include:
1.	 Department of Defense
Medical Treatment Facilities
2.	 Department of Justice
Federal Bureau of Prisons
3.	 Department of Veterans Affairs
Veterans Health Administration Facilities
4. Department of Health and Human
Services
Medicare– and Medicaid–Certified
Nursing Homesa
Source: Scope of the four federal health
care programs.
a. Medicare– and Medicaid–certified nursing homes
are not federally operated, but rather receive
reimbursement for services they provide to
enrollees in Medicare and Medicaid programs.

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Even though the federal health care programs have incentives and strategies to attract and
retain health care personnel, the programs still experienced personnel shortages throughout
the pandemic. Consequently, additional action is necessary to staff normal operations and to
strategically plan for future surges in personnel needed to respond to pandemics and other health
care emergencies. The PRAC encourages policymakers to further explore the impacts of personnel
shortages within the federal health care programs for possible strategies to mitigate staffing
shortages and help ensure high quality, safe, and timely health care is provided to the individuals
the programs serve.
About the PRAC and its Health Care Subgroup
The CARES Act created the PRAC to coordinate oversight of the federal government’s pandemic
response and its historic level of emergency spending. The PRAC’s Health Care Subgroup consists
of OIGs that oversee the federal agencies that provide or reimburse for health care services. By
working together and sharing data, the Health Care Subgroup provides coordinated oversight across
agencies and programs.
Michael E. Horowitz
Chair, PRAC
Inspector General, U.S. Department of Justice
Christi A. Grimm
Chair, PRAC Health Care Subgroup
Inspector General, U.S. Department of Health
and Human Services
Robert P. Storch
Inspector General, U.S. Department
of Defense
Michael J. Missal
Inspector General, U.S. Department
of Veterans Affairs

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Contents
Message from the Pandemic Response Accountability Committee
i
Insights on Shortages of Personnel Across Four Federal
Health Care Programs
1

Agency Details
18
U.S. Department of Defense (DOD)
18
U.S. Department of Justice (DOJ)
38
U.S.  Department of Veterans Affairs (VA)
56
U.S. Department of Health and Human Services (HHS)
67
Appendix A: DOD
83
Appendix B: DOJ
87
Appendix C: VA
89
Appendix D: HHS
92
Appendix E: Shortages Reported by VHA Facilities
95

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Pandemic Response Accountability Committee
As the nation’s health care workforce has responded to the coronavirus disease–2019 (COVID-19)
pandemic (hereinafter referred to as the “pandemic”), maintaining a sufficient level of personnel
in health care facilities has been essential to providing a safe work environment for health care
providers and safe and effective patient care. While personnel shortages existed in the health care
community before the pandemic, the pandemic exacerbated these shortages. As the pandemic
progressed, personnel illnesses, exposures to COVID-19, or the need to care for family members
caused additional staffing shortages. Moreover, one of the federal departments reviewed provided
personnel to assist in the National response to the pandemic, exacerbating shortages within its
health care program.
This report provides Congress, federal and state agencies, health care organizations, and other
policymakers with information on health care shortages across four federal health care programs,
discussed in detail below. Specifically, the report provides insights into shortages in personnel
positions most commonly reported; factors contributing to personnel shortages reported by facility
officials; impacts to the health care personnel, the patients, and health care services provided by
the federal health care programs; and strategies to mitigate personnel shortages caused by or
exacerbated by the pandemic. These insights can help policymakers understand the challenges
that federal health care programs experienced throughout the pandemic and determine the actions
necessary to ensure sufficient staffing for ongoing health care needs and future pandemic response
efforts.
How We Conducted This Review
Four of the Offices of Inspectors General (OIG) in the PRAC Health Care Subgroup participated in
this review—the Department of Defense (DOD), the Department of Justice (DOJ), the Department of
Veterans Affairs (VA), and the Department of Health and Human Services (HHS). The DOD, DOJ, and
VA OIGs reviewed staffing within their internal health care programs while the HHS OIG reviewed
staffing within Medicare– and Medicaid–certified nursing homes. Each OIG reviewed personnel in
the facilities identified below, including clinical positions that deliver patient care and nonclinical
positions such as administrative, logistical, or clerical positions that support patient care. See
Exhibit 1 for more information about the scope of our review.
Insights on Shortages of
Personnel Across Four Federal
Health Care Programs

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Exhibit 1: Scope of Reviewa
DOD
DOJ
VA
HHS
Facilities
Reviewed
Medical Treatment
Facilities (MTF)
Federal Bureau
of Prisons (BOP)
Institutions
Veterans Health
Administration
(VHA) Facilities
Medicare– and
Medicaid–Certified
Nursing Homes
Number of Health
Care Staff
More than
128,000 Service
members and
civilian employeesb
Approximately
3,000 BOP
employees and
U.S. Public Health
Service officersc
More than
371,000 health
care professionals
More than
686,000 direct
care staffd
Population Served
9.6 million active
military members
and their families,
military retirees
and their families,
dependent
survivors,
and certain
eligible Reserve
Component
members and
their families
Approximately
134,000 federal
inmates and
detainees housed
in BOP institutions
More than 9
million enrolled
veterans;
qualifying family
members,
dependents,
and survivors
of veterans;
and eligible
active military
and Reserve
Component
members
1.2 million
Medicare and
Medicaid enrollees
who reside in
nursing homes
Number of
Facilities Within
the Health Care
Program
45 hospitals, 525
outpatient clinics,
and 138 dental
clinics
97 facilities
encompassing
121 BOP
institutions
140 facilities,
encompassing
over 1,200 sites of
care including VA
Medical Centers
and outpatient
settings
15,178 Medicare–
and Medicaid–
certified nursing
homes nationwide
Number of
Facilities
Nonstatistically
Sampled for this
Review
24 hospitals
97 facilities
encompassing
121 BOP
institutions
139 facilities
50 nursing homes
Source: Analysis of data from the four federal health care programs.
a.	 2022 Data; Health care program information detailed above includes only the portions of the programs reviewed for this report.
b.	 The Military Health System (MHS) also used contractors, tracked at the MTF or regional level not MHS-wide, and are not included
in the total. See the section on the U.S. Department of Defense for more information about the MHS.
c.	 The BOP also employs contract medical staff at some institutions who are not included in the total.
d.	 Direct care staff include nursing home employees and staff hired under contract or through staffing agencies.

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
The data and insights are limited to the federal health care programs and the health care personnel
that each OIG chose to review. Personnel data varied across the federal health care programs;
therefore, OIGs collected and reported shortages of personnel based on the data available.
The information provided includes what the federal health care programs experienced, such as
experiences of existing health care personnel and their perceptions of former health care personnel
experiences, during the period of review. The General Methodology section in this report and the
more detailed methodologies in the appendices contain additional information on how each OIG
conducted its analysis.
Shortages of Personnel
INSIGHT: The four federal health care programs each experienced shortages in
personnel before and during the pandemic
The four federal health care programs experienced personnel shortages before and during the
pandemic. According to data provided from or interviews with program officials, the pandemic
exacerbated shortages for the health care programs. For example, officials from Medicare– and
Medicaid–certified nursing homes reported shortages of nurses at 29 of the 50 nursing homes
before the pandemic, compared to 47 nursing homes during the pandemic. Additionally, according
to MTF officials, health care personnel shortages increased during the height of the pandemic and
at the time of the MTF interviews the MTFs had not been able to fill many of the positions. The four
federal health care programs we reviewed experienced shortages in some common positions during
the pandemic.
Nursing positions and medical officers constituted the most commonly reported personnel
shortages during the pandemic
Nursing was one of the most commonly reported positions that experienced shortages in the four
federal health care programs reviewed. Exhibit 2 shows the percentage of sampled facilities in each
federal health care program that reported a nursing shortage during the pandemic.

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Exhibit 2: Percentage of Sampled Facilities by Federal Health Care Program that Reported a
Nursing Shortage During the Pandemic
DOD MTFs
BOP facilities
VHA facilities
Medicare- and
Medicaid-certified
 nursing homes
24 sampled
139 sampled
50 sampled
96 sampled
21
reported
shortages
(88%)
66
reported
shortages
(69%)
127
reported
shortages
(91%)
47
reported
shortages
(94%)
Source: Analysis of nursing shortages reported by facilities in the four federal health care programs.
Notes: Percentages in the chart were calculated using the number of nonstatistically sampled facilities identified in Exhibit 1.
Each OIG accounted for shortages in different ways based on the federal agency’s available data; see each agency’s appendix on
how they reported nursing shortages.
VHA facility percentage is based off responses from the VA OIG’s FY 2022 survey.
Three of the federal health care programs (BOP, MTFs, and VHA facilities) also reported shortages
of medical officers during the pandemic. According to BOP staffing data, 13 of 96 BOP facilities
did not have a medical officer on staff as of March 2022.2 Additionally, officials at 12 of 24 MTFs
interviewed reported medical officers as one of their highest positions in demand. Further, officials
at 121 of 139 VHA facilities reported a shortage in the medical officer series.
In addition to nurses and medical officers, the health care programs experienced shortages in a
variety of other positions that varied by each federal health care program. See Exhibit 3 for the most
commonly reported positions with shortages by facility type.

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Exhibit 3: Top Reported Positions with Shortages
Department
Facility Type
Top Reported Positions with Shortages
DOD
Medical Treatment Facilities
Nurses, Medical Officers, Behavioral Health
personnel, Imaging Technicians, Laboratory
Technicians, Medical Support Assistance personnel
DOJ
Bureau of Prisons Institutions
Nurses, Medical Officers, and Mid-level
practitioners (such as Nurse Practitioners and
Physician Assistants)
VA
Veterans Health Administration
Facilities
Nurses, Medical Officers, Custodial Workers,
Medical Support Assistance, Psychiatry (medical
officer specialty), and Psychology
HHS
Medicare– and Medicaid–
Certified Nursing Homes
Nurses and Aides
Source: Analysis of data from the four federal health care programs, April 2019 through January 2023.
Contributing Factors of Personnel Shortages
INSIGHT: The four federal health care programs faced challenges exacerbated by
or caused by the pandemic that contributed to shortages of personnel
The four federal health care programs we reviewed faced various challenges that contributed to
personnel shortages.
A limited labor pool, noncompetitive pay, COVID-19 requirements, and a challenging hiring
process were the most commonly reported factors that contributed to personnel shortages
Officials from the four federal health care programs reported that the shortages stemmed from
a limited labor pool of health care personnel such as doctors and nurses. The four federal health
care programs also reported that noncompetitive pay compared to other health care facilities
contributed to personnel shortages. According to BOP, MTF, and nursing home officials we
interviewed, the facilities had difficulties recruiting or retaining their personnel because other
health care facilities offered higher pay. For example, in an announcement obtained in January
2023, a private health care company posted a job paying $81,120 annually for a vocational nurse,
which was $33,504 more than a vocational nurse position posted for an MTF at a location 7 miles
away.3 Additionally, nursing home officials we interviewed stated that their facilities lost health care
personnel during the pandemic to higher paying jobs in other industries.

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Programs During the COVID-19 Pandemic
Officials from two of the four federal health care programs (BOP and MTFs) also identified
noncompetitive pay compared to other federal agencies as a contributing factor that led to
personnel shortages. In 1975, Congress first authorized VA to offer higher salaries to physicians
and dentists using title 38 authority. Since then, Congress has expanded the authority to offer
higher salaries to other health care positions such as physician assistants, podiatrists, and nurses.4
The Office of Personnel Management (OPM) extended title 38 authority to the DOD and DOJ in 2012
and 2014, respectively; however, since then the Departments have applied title 38 authority to only
a few medical positions.5 Both the BOP and MTFs have used title 38 authority to hire physicians
and dentists. Additionally, the BOP has used the authority to hire psychiatrists. Officials at 13
MTFs stated that they had personnel shortages during the pandemic because the MTFs could not
compete with nearby VHA facilities. Specifically, MTFs could not compete with VHA facilities that
offered higher salaries for positions that the MTFs have not applied title 38 authority.
Officials from three of the federal health care programs (MTFs, BOP, and Medicare– and
Medicaid–certified nursing homes) reported factors caused by the pandemic that contributed to
personnel shortages, such as increased job requirements and COVID-19 quarantine. According
to MTF officials, pulling health care personnel from their duties at the MTF to support pandemic
requirements such as COVID-19 testing, vaccinations, and contact tracing, coupled with quarantine
protocols and travel restrictions contributed to shortages of personnel in the MTFs. Additionally,
according to officials from 26 of the sampled nursing homes, the requirement to quarantine
personnel who contracted or were exposed to COVID-19 left nursing homes short-staffed during
those periods. Nursing home officials also reported that some personnel were not able to work
because they had to take care of family members that contracted COVID-19, or they quit their job
after they contracted COVID-19. Finally, the BOP also experienced personnel shortages due to staff
illness with COVID-19, with one of its institutions reporting that 75 percent of its health services unit
had to take sick leave to recover from a COVID-19 outbreak.
Officials from three of the four federal health care programs (MTFs, BOP, and VHA) also reported
that a challenging hiring process, made worse by the pandemic, contributed to personnel
shortages. MTF officials stated that the hiring process sometimes took up to 6 months, with
officials from one MTF stating that it took up to 24 months to hire personnel. Officials from other
MTFs stated that they lost multiple applicants or had delays in the onboarding process because
of the time it took for security and credentialing checks, as well as delays in obtaining common
access cards because no one was working in-person at the identification card office during the
height of the pandemic. According to BOP officials, the process to hire personnel to work for the
federal government is different from the process that private sector health care professionals are
accustomed to, taking more time, and involving nuances in the job postings and application process
that may prevent applicants from applying to or being selected for available job opportunities.
Officials from VHA facilities also reported recruitment challenges, including the hiring process, as a
contributing factor for personnel shortages.
See Exhibit 4 for contributing factors reported by personnel from at least three of the four federal
health care programs.

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Programs During the COVID-19 Pandemic
Exhibit 4: Most Commonly Reported Factors That Contributed to Personnel Shortages
Contributing Factor
DOD MTFs
BOP Institutions
VHA Facilities
Medicare– and
Medicaid–Certified
Nursing Homes
Limited Labor Pool
Noncompetitive Pay
COVID-19 Requirements
Challenging Hiring Process
Source: OIGs’ interviews with or surveys of facility officials.
In addition, officials reported other factors contributing to personnel shortages unique to their
federal health care program. For example, MTF officials reported that active duty health care
personnel were pulled from the MTFs to provide support for the Nation’s pandemic response and
other worldwide missions, creating additional shortages of health care personnel. BOP officials
reported that providing health care to prisoners included requirements that private sector nurses
do not have to deal with such as wearing a stab vest, carrying handfuls of keys, and carrying pepper
spray. Additionally, officials at Medicare– and Medicaid–certified nursing homes reported that
personnel quit their jobs because of their fear of COVID-19 infection while caring for nursing home
residents.
Impacts of Personnel Shortages
INSIGHT: The four federal health care programs experienced a decrease in patient
access to care and patient satisfaction, coupled with an increase in work hours
and responsibilities as a result of personnel shortages
Patient Impacts. Officials from the four federal
health care programs we reviewed reported
personnel shortages that impacted patients.
Officials from all 24 MTFs interviewed cited
decreased patient access to care, decreased
patient satisfaction, and reduced preventative
screenings because of shortages of health care
personnel. According to an April 2021 survey
on federal inmates’ experiences during the
pandemic, an estimated 80 percent of inmates
rated BOP’s provision of medical care as poor
during pandemic lockdowns, compared to an
Exhibit 5: Examples of Patient Impacts Reported
•	 Decreased access to care
•	 Decreased patient satisfaction
•	 Decreased face-to-face interactions with providers
•	 Delay of patient admissions or transfers from
hospitals to nursing homes
•	 Overall decline in patient physical and mental
health
Source: Analysis of data from the four federal health
care programs.

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Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
estimated 41 percent of inmates who described the provision of medical care as “poor” before the
pandemic. The VHA reported shortages in occupations considered essential to delivering safe care,
meeting the growing demand for mental health care, and supporting the expansion of telehealth.
Officials from 26 of the 50 Medicare– and Medicaid–certified nursing homes reported an overall
decline in resident’s physical and mental health because of shortages of health care personnel
and lower levels of care. Specifically, officials stated that the nursing homes had to adjust the
level of care provided to residents, including reducing or stopping restorative care and physical
rehabilitation services, and sending residents who needed wound care to the hospital.
Health Care Personnel Impacts. Officials from the four federal
health care programs reported impacts to their personnel
because of personnel shortages. Officials from all 24 MTFs
sampled stated that shortages of health care personnel resulted
in increased duties and work hours for the remaining personnel,
decreased morale, and decreased access to medical cases that
are necessary for providers to gain or maintain their medical
skills. BOP officials reported an increase in workload for health
care personnel at BOP institutions because they handled
large numbers of inmate illnesses due to COVID-19, as well as
taking on new responsibilities, such as screening and testing
for COVID-19 and monitoring quarantine and isolation units.
Officials from Medicare– and Medicaid–certified nursing homes
stated that the personnel shortages resulted in: (1) personnel
increasing their workloads, often working longer shifts and covering the shifts of other personnel,
and (2) more staff calling out of work to avoid increased workloads. Officials also stated that these
conditions led to burnout and increased levels of stress, anxiety, and depression. Directors from the
VHA’s Veterans Integrated Service Networks reported burnout among human resources personnel
because of the unanticipated workload associated with the hiring surge to address personnel
shortages caused by the pandemic.
Financial Impacts. Three of the four health care programs (BOP,
MTFs, and Medicare– and Medicaid–certified nursing homes)
experienced financial impacts because of health care personnel
shortages. The DOJ OIG assessed BOP’s overtime spending and
found that BOP health services personnel worked more than
314,000 overtime hours during the first year of the pandemic, at
a cost of $15 million, an increase of 56 percent and 64 percent,
respectively, compared to the overtime hours worked and costs
expended in the year before the pandemic. Similarly, reports
from one MTF show that overtime hours for its civilian employees
increased almost 50 percent from 2019 to 2020 when the
pandemic began, increasing from 1,200 hours in 2019 to 1,800
hours in 2020. Finally, officials from all 50 Medicare– and Medicaid–certified nursing homes that
HHS OIG interviewed stated that they incurred higher costs for employee bonuses, overtime, and
contracted agency staff.
Exhibit 6: Examples of Personnel
Impacts Reported
•	 Increased responsibilities
•	 Increased hours worked
•	 Decreased morale
•	 Increased burnout
•	 Increased risk of mental health
illnesses
Source: Analysis of data from the
four federal health care programs.
Exhibit 7: Examples of Financial
Impacts Reported
•	 Increased costs for overtime
•	 Increased costs for bonuses
•	 Increased costs for contracted
agency staff
Source: Analysis of data from the
four federal health care programs.

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Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Strategies to Mitigate Personnel Shortages
INSIGHT: The four federal health care programs used incentives and other
strategies to recruit new staff, retain existing staff, and minimize health care
personnel burnout
The four federal health care programs we reviewed used incentives and other strategies to reduce
personnel shortages and minimize personnel burnout. Many of these strategies existed prior to the
pandemic and were similar across the four programs. Mitigation strategies implemented during
the pandemic included awarding contracts with higher wages and implementing waivers to the
onboarding process to hire personnel more quickly.
Monetary incentives were the most commonly reported recruiting and retention strategy used
by the health care programs, followed by unique efforts developed by individual facilities, and
increased work flexibilities
The four federal health care programs used monetary incentives, including bonuses and other
programs to increase base pay, to recruit and retain health care personnel during the pandemic.
Three of the four federal health care programs (BOP, MTFs, and VHA facilities) were authorized
to use portions of title 38 for increased salaries and added flexibilities in hiring to recruit and
retain employees in certain health care occupations; however, the MTFs and the BOP applied title
38 authority to two (physicians and dentists) and three occupations (physicians, dentists, and
psychiatrists), respectively. Additionally, the BOP and Medicare– and Medicaid–certified nursing
homes increased starting salaries for health care personnel and VHA facilities increased the
maximum pay cap for nurses in accordance with Congressional legislation. The MTFs also used
contracts offering higher pay to bring in additional personnel. Several BOP officials stated that the
most effective recruitment incentive involved monetary compensation. However, BOP officials also
stated that low pay was the main driver of turnover in their health care personnel. Similarly, the MTF
officials stated that even with monetary incentives, DOD compensation still could not compete with
the private sector or other federal agencies.
The four federal health care programs used student loan repayment or tuition assistance to
encourage health care personnel to work for their programs. Additionally, three federal health care
programs offered flexibility with work schedules and locations as a strategy to reduce personnel
shortages. Personnel at Medicare– and Medicaid–certified nursing homes were offered flexible
hours. Officials at BOP institutions approved compressed work schedules to allow employees
additional flexibilities. Lastly, officials at the MTFs stated that they offered telework, virtual
telehealth, remote opportunities, and alternative work schedules, when available, and provided
personnel with scheduling flexibility so they could balance their patient workload with administrative
tasks.

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Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Strategies to minimize burnout varied across the federal health care programs
The four federal health care programs made efforts to retain existing staff and minimize personnel
burnout. MTF officials stated that they encouraged employees to use leave, and stated that they
recognized employees with time-off awards, command recognition, letters of appreciation, and
early releases from work on special occasions, such as federal holidays. BOP officials stated that
they encouraged personnel to access the BOP’s Employee Assistance Program and encouraged
management to monitor and support staff well-being. VHA established the Reduce Employee
Burnout and Optimizing Organizational Thriving (REBOOT) Task Force to address drivers of burnout
including unmanageable workload, perceived lack of fairness, lack of job control, low recognition or
organizational support, interpersonal conflict, and mismatched values. At Medicare– and Medicaid–
certified nursing homes, leadership tried to reduce provider burnout by reducing the number of
new resident admissions, delaying new admissions, or admitting only residents who required less
frequent or less intensive care. Additionally, the nursing home leadership created staff sharing
agreements with facilities under the same corporate ownership and honored time-off requests
when possible to reduce provider burnout.

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Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
Conclusion
The reported impacts to patients and health care personnel during the pandemic highlight the
importance of identifying and understanding personnel shortages within federal health care
programs. This report summarizes the most commonly reported positions with shortages,
factors contributing to shortages, impacts most commonly encountered, and the incentives and
other strategies used to recruit new personnel, and retain and minimize burnout for existing
personnel across the four federal health care programs. Although this report does not represent a
comprehensive review of personnel shortages in all federal health care programs, it could provide
insights on similar circumstances across other federal health care programs in addition to the four
federal health care programs reviewed.
The insights summarized below are intended to help Congress, federal and state agencies, health
care organizations, and other policymakers—understand the most commonly reported positions
with shortages, what contributed to those shortages, and how the shortages affected the programs’
patients and health care personnel. OIGs identified the following key insights across the four federal
health care programs reviewed.
•	 Nurses and medical officers were the most commonly reported positions that experienced
shortages during the pandemic.6
•	 A limited labor pool, noncompetitive pay, COVID-19 requirements, and a challenging hiring
process were the most commonly reported factors that contributed to personnel shortages.
•	 A decrease in patient access to care and patient satisfaction and an increase in health care
personnel work hours and responsibilities were the most commonly reported impacts resulting
from personnel shortages.
•	 Monetary incentives were the most commonly reported strategy to recruit and retain
personnel.
These insights highlight that actions are necessary to ensure the federal health care programs are
staffed sufficiently to continue normal operations, as well as strategically plan for surges of health
care personnel needed to respond to future pandemics and other health care emergencies. The
PRAC encourages policymakers to further explore the impacts of personnel shortages within the
federal health care programs to develop strategies to mitigate staffing shortages and help ensure
quality, safe, and timely health care is provided to the individuals the programs serve.

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Pandemic Response Accountability Committee
Personnel Shortages in Federal Health Care
Programs During the COVID-19 Pandemic
General Methodology
Each of the four participating OIGs selected a health care program within its Department, or
providers it reimburses, to review staffing shortages before the pandemic (January 1, 2019 -
February 29, 2020), and during the pandemic (March 1, 2020 – January 2023).
Data Collection and Analysis
Each OIG collected staffing shortage data from health care providers and administrators for their
respective health care program to answer the following questions.
1.	 Does the federal health care program, or providers it reimburses, have shortages of health
care personnel?
2.	 If there are health care personnel shortages, what were the causes of the shortages?
3.	 What were the impacts of the health care staffing shortages?
4.	 What strategies did the health care program, or providers it reimburses, have to attract new
health care personnel, and retain and minimize burnout for existing health care personnel?
Data Collection
To ensure a level of standardization and consistency, the DOD OIG, in collaboration with the other
participating OIGs and the PRAC, developed a framework to guide data collection and analysis.
Because the federal health care programs vary, each OIG determined which data sources to use
in its analyses and coordinated, as necessary, with officials from its federal health care program to
obtain this data. OIGs collected data about health care personnel levels and shortages, specialties
or positions most affected by shortages, causes and impacts of shortages, and actions health care
programs are taking to mitigate shortages.
Data Analysis
Each OIG analyzed health care personnel shortages, causes, impacts, and mitigating strategies
for its federal health care program and provided the DOD OIG with the results of its analysis. The
DOD OIG then reviewed the findings from the four federal health care programs to provide broader
insights and shared the insights with the other OIGs for review of information related to their
respective section. For agency-specific details about the data and analysis, refer to the methodology
section in the appendix.
Data Reviewed for Each of the Federal Health Care Programs
MTF. The results reported in this review include the expertise and experiences of officials from 24
nonstatistically selected MTFs, as well as officials from the Defense Health Agency (DHA), office of

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Programs During the COVID-19 Pandemic
the Assistant Secretary of Defense (Health Affairs), and Service medical commands. Information
and examples were collected during interviews with the MTF officials, such as the MTF directors,
hiring officials, manpower personnel, and others. Sources of data used to corroborate statements
made are cited throughout the report. Our scope included active duty Service members, civilians,
and contractors in the MTFs, or DOD direct care; however, staffing data provided for authorized
and filled positions is only for civilian personnel under the DHA as of January 2023, and does not
include active duty Service members or contractors employed at the MTFs, or civilians employed by
the Military Departments.
BOP Health Care Services. The health care personnel data discussed in this review include
information about BOP civil service employees and commissioned officers of the U.S. Public Health
Service who work in the health services units at BOP’s institutions; however, it does not include
the BOP’s psychology services staff, who are considered separate from health services in the
BOP’s organizational structure. This review does not include information about contract health
care providers who deliver specialized care to BOP inmates at community facilities or on-site at
BOP institutions or who are hired on a short-term basis to fill vacancies. Although there are 121
BOP-managed institutions, BOP considers the federal correctional complexes, in which multiple
institutions are co-located, to be a single facility when reporting staffing data. Therefore, the total
number of facilities described in the staffing data and this review is 97. When examining only clinical
staffing, the total facilities decreases to 96 because FCC Beaumont uses only contract clinical staff.
VHA. The health care personnel shortages discussed in this review include only occupations
employed by VHA. This review summarizes information on shortages in health care personnel at
139 VHA facilities for FYs 2020-2022, including data gathered through an annual VA OIG survey.
Nursing Homes. This review includes the experiences of staff who were employed or contracted by
Medicare– and Medicaid–certified nursing homes. Information obtained for this review included
data on:
•	 staffing shortages that nursing homes reported to the Centers for Disease Control and
Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) for the weeks ended May 24,
2020, through September 11, 2022;
•	 nursing home staffing information based on payroll and other verifiable and auditable data
that nursing homes reported in the Centers for Medicare & Medicaid Services’ (CMS’s) Payroll-
Based Journal (PBJ) system for the quarters ended June 30, 2019, through June 30, 2022;
and
•	 interviews with officials from 50 selected nursing homes about their experiences with staffing
shortages both before and during the pandemic.7

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Limitations
This report does not present a comprehensive review of health care personnel shortages before
and during the pandemic across all health care programs either provided through or administered
by the Federal Government. The data and insights are limited to the federal health care programs
and the types of health care personnel that each OIG chose to review. Personnel data varied across
the federal health care programs; therefore, OIGs collected and reported shortages of health care
personnel based on the data available to them. The information provided reflects the experiences of
existing health care personnel and their perceptions of former health care personnel experiences,
during the period of review. Therefore, officials may not have captured all reasons for shortages
in health care personnel, the impacts of the shortages, or their efforts to attract and retain
staff, or minimize staff burnout. Additionally, OIGs did not verify the accuracy of the contributing
factors, impacts, or efforts with shortages in health care personnel that were shared by officials
during interviews. For agency-specific limitations, see each OIG’s detailed methodology in the
corresponding appendix.
Standards
The DOD OIG and HHS OIG conducted their work in accordance with the generally accepted
government auditing standards (GAGAS) issued by the U.S. Government Accountability Office,
and the DOJ OIG and VA OIG conducted their work in accordance with the Quality Standards
of Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and
Efficiency (CIGIE). Each OIG followed its own processes to ensure that its contributions to this report
met GAGAS or CIGIE standards, and they provided an attestation to the PRAC stating that it met
those standards. This review was conducted under CIGIE’s Quality Standards of Inspection and
Evaluation.

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Glossary
Alternative work schedule: Both flexible work schedules and compressed work schedules.
Augmentation: The practice of assigning non-custody staff, such as teachers or health care
professionals, to temporarily assume the duties of a correctional officer. BOP staff are considered
correctional workers first, regardless of their occupation.
Authorized position: Billet or position for which the quality of the requirement has been validated
and authorized to perform the billet functions.
Billet: A specific military or civilian manpower space, which is assigned qualifiers that define the
duties, tasks, and functions to be performed and the specific skills and skill level required to
perform the delineated functions.
Bureau of Prisons (BOP) facilities: Federal correctional institutions, detention centers, U.S.
penitentiaries, and correctional complexes that house federal inmates and pre-trial detainees.
Federal correctional complexes are facilities in which multiple institutions of varying security level
are co-located.
Burnout: A result of chronic workplace stress characterized by feelings of energy depletion or
exhaustion, increased mental distance from one’s job or feelings of negativism or cynicism, and a
sense of ineffectiveness.
Clinical staff/personnel: Clinical staff are health care personnel who deliver patient care.
Contact tracing: A process to identify people that came in close contact with a person infected by
COVID-19.
Compressed work schedule: A fixed work schedule that enables a full-time employee to complete
an 80-hour biweekly basic work requirement in less than 10 workdays.
Department of Defense medical treatment facilities: Military hospitals or clinics that provide
direct care for beneficiaries.
Direct hire authority: The authority to make noncompetitive appointments based on a
determination by OPM or the Secretary of that Department that a severe occupational shortage of
highly qualified candidates exist for applicable occupations.
Filled position: Occupied billet or position performing the functions of the authorized position; the
number of staff onboard.

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Programs During the COVID-19 Pandemic
Flexible work schedule: A flexible work schedule allows an employee with an 80-hour biweekly
basic work requirement to determine their own schedule within the limits set by the agency.
General schedule: The general schedule (GS) pay system covers the majority of civilian white-collar
federal employees in professional, technical, administrative, and clerical positions, with grades
ranging from GS-1 (lowest) to GS-15 (highest).
Health care personnel: Personnel that provide clinical or nonclinical services in a health care
setting.
Lockdown: In BOP institutions, periods of time during which inmate movement is restricted,
generally to their cells or housing units, to address safety and security issues within the facilities.
During the COVID-19 pandemic, the BOP imposed inmate movement restrictions, sometimes called
“Shelter in Place” or “modified lockdown” as a strategy to mitigate exposure to and spread of
COVID-19.
Medical officer: Positions with duties that advise on, administer, supervise or perform professional
and scientific work in one or more fields of medicine, and when the degree of Doctor of Medicine or
Doctor of Osteopathy is a fundamental requirement.
Medicare– and Medicaid–certified nursing homes: Nursing homes that are required to comply
with health and safety requirements in federal regulations (42 C.F.R. part 483, subpart b) to
participate in the Medicare and Medicaid programs.
Nonclinical staff/personnel: Health care personnel whose responsibilities are administrative,
logistical, or clerical in nature to support clinical staff who provide care or medical treatment to
patients.
Nursing homes: Facilities that provide services to individuals whose capacity for self-care is limited
because of a chronic illness; injury; physical, cognitive, or mental disability; or other health-related
conditions.
Occupational Series Code: OPM codes used to group positions with a similar specialized line of
work and qualification requirements. For example, GS-0610 is the Nursing Series.
Regional health services administrators: Regional Health Systems Administrators (HSA) serve
as principal advisors to the Regional Director and Deputy Regional Director in all matters related
to health care delivery.  The primary responsibilities of the regional HSAs include developing
suggestions for policy revisions, perform management assessments, and responding to health care
problems at all institutions within the region (including Residential Reentry Centers). There are six
regional HSAs positions corresponding with the BOP’s six regions.
Shortages: Positions with vacancies or positions that are difficult to fill, to meet a desired or
statutory level, which may or may not impact the level of care provided.

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Sick call: Within the BOP, the process by which inmates request and receive routine or preventative
medical care.
Title 38 authority: Personnel authorities for health care occupations primarily available to VA, with
some personnel authorities delegated by OPM for discretionary use by other federal agencies.
Veterans Health Administration facilities: Sites of care including VA Medical Centers and
outpatient settings that provide services to veterans; qualifying family members, dependents, and
survivors of veterans; and eligible active military and Reserve Component members.

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DOD
DOJ
VHA
HHS
U.S. Department
of Defense (DOD)
According to the DHA, the Military Health System (MHS) is the most comprehensive military health
care enterprise in the world. The MHS provides direction, resources, health care providers, and
other means necessary to foster, protect, sustain, and restore health to over 9.6 million active
duty Service members, military retirees, and their families. Health care services are delivered
through two systems—the direct care system consisting of the DOD’s MTFs, located worldwide, and
the purchased care system consisting of partnerships with civilian health care provider facilities
operated through TRICARE regional contracts (referred to as the “civilian network” throughout this
review).8
Medical Treatment Facility Personnel
The MTFs, or military hospitals and clinics, are critical to military medicine, where military, civilian,
and contract personnel provide direct care for beneficiaries and gain the skills and training to
support operational units. As of December 2, 2022, the DOD’s direct care system consisted of 45
military hospitals, 525 outpatient and occupational health clinics, and 138 dental clinics. The MTFs
are led by an MTF Director or Commander, and include personnel in areas such as administration,
medical delivery, and ancillary support. The MTFs vary in size and offer different services; therefore,
personnel staffing these facilities range from primary care providers to a wide range of specialists,
including providers for mental health, obstetrics, urology, and dermatology.
Military Health System Transition
According to the DHA FY 2022-2026 campaign plan, by 2026, the DHA will be a joint operational
headquarters responsible for managing, executing, and delivering high-quality health care,
medical education and training, military medical research and development, and public health
support to the MHS’ beneficiaries and the Services. Section 702 of the FY 2017 National Defense
Authorization Act (NDAA) and sections 711 and 712 of the FY 2019 NDAA required that the
Military Departments transition the administration of all the MTFs to the DHA for the purpose of
implementing an integrated system of readiness and health.9
The Deputy Secretary of Defense paused the MHS transition from April 2, 2020, through November
9, 2020, to realign personnel and resources to support the pandemic mission. The transition
resumed after the pause and in a February 24, 2022, memorandum, the Deputy Secretary of

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Defense directed the continued implementation of the MHS organizational reform by directing the
DHA to assume authority, control, and direction of military hospitals, clinics, and dental treatment
facilities, to include the MTFs located overseas. At the time of our interviews, the MTFs transitioned
or were in the process of transitioning their civilian personnel to the DHA. According to officials in
the Human Capital Division at the DHA, the DHA completed the transition of the MTFs on October
23, 2022. The last milestone of the MTF transfer included transferring the MTF civilian personnel
from the Military Departments to the DHA. However, active duty Service members working in the
MTFs will remain the responsibility of their respective Military Departments.
COVID-19’s Impact on the Military Health System
The pandemic had a major impact on the DOD and the MHS. Early in the pandemic, the MTF
officials reported facing challenges delivering health care at the MTFs with inadequate amounts
of COVID-19 testing supplies and personal protective equipment while also having to adapt to
delivering health care virtually for many patients. As the pandemic progressed and the Nation
experienced shortages of health care personnel, DOD officials confirmed that the MTFs were
experiencing shortages as well.
On January 12, 2022, the Under Secretary of Defense for Personnel and Readiness submitted
a report to Congress addressing the shortage of behavioral health providers in the DOD, using
data available from before the pandemic.10 The report identified recruitment challenges facing
the direct care network including active duty authorizations, dedicated funding and personnel
for recruitment, salary caps, lengthy hiring processes, insufficient compensation packages for
remote locations, and national behavioral health provider shortages. The report identified that the
law limits compensation for civilians and active duty providers, making recruitment and retention
difficult. Although the report to Congress supported recruitment challenges prior to the pandemic,
the MTF officials reported that recruiting behavioral health providers was even more difficult during
the pandemic.
Additionally, in April 2022, the DOD OIG highlighted shortages of health care personnel in the
direct care network, citing that officials at 26 of 30 MTFs reported staffing shortages as the most
serious challenge encountered by medical personnel during the pandemic. The MTF officials
reported that while the staffing shortages, in part, were not a direct result of the pandemic, the
additional requirements that accumulated over the course of the pandemic, with decreased staff
for pandemic response, resulted in health care providers and clinical personnel being overworked
and feeling burned out.11

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Scope of DOD OIG Review
This review provides information on shortages of active duty, civilian, and contractor health care
personnel at 24 of the DOD’s 45 hospitals and their associated clinics in the direct care system,
as of December 2022. We conducted interviews with key MTF officials on clinical and nonclinical
personnel working at the MTFs.12 Our review includes data on health care personnel in the direct
care system before the pandemic, March 1, 2019, to February 29, 2020, and during the pandemic,
March 1, 2020, to January 2023.
This review does not include shortages of health care personnel in the purchased care, or civilian
network of providers that provide health care services beyond the MTFs. Additionally, the DHA
provided staffing data for authorized and filled positions for only civilian personnel under the DHA’s
authority, direction, and control, as of January 2023. The data does not include active duty Service
members or contractors employed at the MTFs, or civilians employed by the Military Departments.
See Appendix A: DOD for the DOD OIG’s methodology.

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Health Care Personnel Shortages Before and During
the Pandemic
The MTFs experienced shortages of health care personnel before and during the pandemic. In
April 2022, we reported that officials from 26 of 30 MTFs sampled indicated staffing challenges
and shortages were the most serious challenges encountered by medical personnel working at
the MTFs during the pandemic.13 Additionally, we reported that officials from 11 of the 30 MTFs
indicated staff burnout and fatigue were the most serious concern that they would encounter in the
future. During that effort, we conducted interviews with the MTF officials from September 9, 2021,
through October 4, 2021, where the MTF responses reflected a point in time with personnel in place
at the MTF before or during the height of the pandemic. To determine whether shortages of health
care personnel were still a concern for this review in support of the PRAC, we obtained data and
conducted interviews with officials working at 24 of the MTFs that previously reported, as part of the
April 2022 report, staffing shortages or burnout as the most serious challenge or future concern.
The MTFs did not provide consistent data to compare authorized and filled positions, before
and during the pandemic, across our sample. However, the DHA provided personnel data as of
January 2023 for the civilians under the DHA’s management and administration. These personnel
accounted for only a portion of health care personnel within the MTFs, and they did not include
active duty Service members, contractors, or civilians under the Military Departments’ management
and control. Generally, the MTFs outside the continental United States employ more active duty
Service members, as it is more challenging to hire civilians in those facilities. Therefore, the vacant
civilian billets and percentages unfilled reported in Exhibit 1 represent only a portion of the MTF
workforce.
Based on the DHA staffing data, there were over 6,000 civilian positions across the MTFs we
sampled that were vacant as of January 2023. The data provided was not broken down by position
to determine what civilian health care personnel positions had the largest shortages. However, over
80 percent of the civilian vacancies were positions within medical centers, which are the DOD’s
largest MTFs that provide a range of specialty and subspecialty care, serve as trauma centers for
the Military and the community, and usually participate in General Medical Education and medical
research programs. Additionally, many of the vacancies were at hospitals located in or near large
metropolitan areas, such as Seattle, Washington; Washington, DC; and San Diego, California. See
Exhibit 1 for the DHA civilian billets that were filled and vacant, as of January 2023, for the 24 MTFs
we sampled.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Exhibit 1: January 2023 DHA Civilian Billets Authorized and Vacant for the 24 Sampled MTFs
Tripler Army Medical Center
Naval Hospital Rota
Womack Army Medical Center
48th Medical Group (Royal Air Force Lakenheath)
Naval Hospital Sigonella
Martin Army Community Hospital
Naval Hospital Jacksonville
Naval Hospital Camp Pendleton
William Beaumont Army Medical Center
Naval Hospital Guam
Naval Medical Center Camp Lejeune
60th Medical Group (Travis Air Force Base)
Weed Army Community Hospital
Naval Hospital Bremerton
Naval Hospital Twentynine Palms
Walter Reed National Military Medical Center
Landstuhl Regional Medical Center
Naval Medical Center San Diego
673d Medical Group (Joint Base Elmendorf-Richardson)
Naval Medical Center Portsmouth
Blanchfield Army Community Hospital
51st Medical Group (Osan Air Base)
88th Medical Group (Wright-Patterson Air Force Base)
Madigan Army Medical Center
1,615
168
3
524
473
45
499
248
770
21
68
51
71
456
145
175
27
98
238
3
9
446
2
87
38%
36%
33%
29%
28%
27%
25%
25%
24%
22%
22%
22%
22%
21%
21%
20%
19%
18%
16%
15%
15%
14%
10%
5%
Civilian billets vacant
Civilian billets filled
Source: Data provided by the DHA from the Defense Civilian Personnel Data system and the DHA’s Joint Table of Distribution, January
2023.
There were eight MTFs that had 25 percent or more of their DHA civilian positions vacant. These
MTFs were generally located in or near large metropolitan areas or located in areas outside of the
continental United States. Table 1 lists the MTFs that had 25 percent or more of their DHA civilian
positions vacant.

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Table 1: The MTFs That Had 25 Percent or More of Their DHA Civilian Positions Vacant
MTF
% of DHA Civilian
Billets Unfilled
Madigan Army Medical Center
38
88th Medical Group (Wright-Patterson Air Force Base)
36
51st Medical Group (Osan Air Base)
33
Blanchfield Army Community Hospital
29
Naval Medical Center Portsmouth
28
673d Medical Group (Joint Base Elmendorf-Richardson)
27
Naval Medical Center San Diego
25
Landstuhl Regional Medical Center
25
Source: DOD OIG analysis of data provided by the DHA from the Defense Civilian Personnel Data system and the DHA’s Joint Table of
Distribution, January 2023.
Note: Percentages are rounded.
We interviewed 220 officials at the 24 MTFs to obtain their input and obtain documentation
to determine the health care positions that the MTFs were experiencing the largest shortages.
Officials we interviewed at all 24 MTFs reported that as of September 2022 their MTFs were
experiencing shortages of health care personnel. The MTF officials stated that nurses, medical
officers, behavioral health personnel, imaging technicians, laboratory technicians, and medical
support assistants were in highest demand.14 According to the MTF officials, health care personnel
shortages increased during the height of the pandemic and at the time of the MTF interviews, held
between August and September 2022, the MTFs had not been able to fill many of the positions. See
Exhibit 2 for the highest reported shortages by position type for the 24 MTFs interviewed.

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Exhibit 2: Number of MTFs That Reported Staffing Shortages Before or During the Pandemic,
by Position
21
14
13
13
12
10
Nurses
Behavioral
Health
Personnel
Imaging
Technicians
Lab
Technicians
Medical
Officers
Medical Support
Assistance
Personnel
Source: DOD OIG interviews with officials from sample of MTFs, August through September 2022.
Note: The totals represent the number of MTFs out of 24 that officials reported the position types. Officials interviewed did not always
indicate whether the positions were short before or during the pandemic, so they are not specified in this figure.

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Contributing Factors That Led to Shortages of Health
Care Personnel
DOD officials from the 24 MTFs we interviewed identified various contributing factors for shortages
of health care personnel during the pandemic. See Exhibit 3 for the most commonly reported
contributing factors of health care personnel shortages reported by the MTF officials.
Exhibit 3: Number of MTFs That Reported the Top Contributing Factors That Led to Personnel
Shortages
Noncompetitive Pay
COVID-19 Requirements
Hiring Timelines
Limited Labor Pool
Mission Support
Federal and DOD-Imposed
 Restrictions
19
19
18
18
17
8
Source: DOD OIG interviews with officials from sample of the MTFs, August through September 2022.
Note: The totals represent the number of the MTFs out of 24 that officials reported the cause.
Noncompetitive Pay
The MTF officials reported that pay offered by the DOD was not competitive with pay provided by the
private sector and VHA facilities, which was exacerbated by the pandemic, resulting in health care
personnel shortages.
Private Sector Competition | Officials at 19 MTFs stated they lost personnel, such as physicians,
nurse practitioners, physicians’ assistants, nurses, technicians, and even housekeepers to civilian
hospitals in the area for higher pay. For example, one MTF provided salary data for housekeepers
in their area, quoting that a corporate hotel offered pay of $33,408 to $73,080 annually, a civilian
hospital could offer $64,728 to $68,904 annually, and the MTF could only offer $32,635 to
$38,544 annually.

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Officials at another MTF stated that civilian hospitals in the network were paying nurses $71 an
hour in an inpatient unit, while an inpatient nurse at their MTF made $43 to $44 an hour as a GS-
11 civilian position, which resulted in a significant pay gap. Furthermore, an MTF job announcement
obtained in January 2023 for a vocational nurse offered $47,616 annually as a GS-6, while a
private sector facility that was seven miles away, offered $81,120 annually, or $33,504 more than
the DOD position. Additionally, the Director of Medical Services at one MTF stated that a trauma
surgeon could make $1 million dollars a year in the public sector. However, DOD and federal
requirements prohibit personnel in the Federal Government from making more than the President’s
salary of $400,000 a year.15 The MTF officials at one location stated that the cost of living in their
area had increased dramatically during the pandemic and the stagnant pay scales within the DOD
could not compete with the private sector. The Deputy Commander for Clinical Services for one MTF
stated that they received job offer letters every day from civilian hospitals offering less work for
more pay.
The MTFs attempted to recruit additional temporary staff during the pandemic to assist with
personnel shortages and the additional workload requirements added by the pandemic by using
surge contracts. However, according to the MTF officials, the surge contracts that offered higher
pay still could not compete with the pay offered in the public sector. Further, an official from one
MTF stated that there was nothing in the surge contracts to prevent the existing contract staff from
applying. Therefore, the contract staff that already worked in the MTF moved to the surge contract
to obtain higher wages, which did not help the MTF with hiring during the pandemic.
VHA Facility Competition | Officials at 13 MTFs stated that they had personnel shortages during
the pandemic because the MTFs could not compete with nearby VHA facilities. Specifically,
according to the MTF manpower personnel, the VHA can offer positions with pay one grade higher
than the MTFs based on the use of title 38 authority.16 For example, an official from one MTF
stated that they lost licensed practical nurses to the VHA because the VHA could offer them a
position at a higher grade, resulting in a higher salary. An official from another MTF stated that
they lost eight primary care providers to the VHA because of the differences in pay. While the DOD
currently has title 38 authorities for pay for physicians and dentists, it cannot compete with title 38
salaries offered for other disciplines because the DOD has not fully taken advantage of its title 38
authorities.
Pandemic Requirements
The MTF officials stated that pulling health care personnel from their duties at the MTF to support
pandemic requirements such as COVID-19 vaccinations, testing, and contact tracing, as well as
protocols for quarantine and travel restrictions contributed to shortages of personnel in the MTFs.
According to the MTF officials, the MTFs lacked staff to perform the additional responsibilities
created by the pandemic, such as COVID-19 testing and vaccinations, resulting in the use of existing
staff to perform these duties. An official from one MTF stated that COVID-19 testing required the

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
MTF lab staff, patient administration staff, and providers to work 12-hour shifts to enable 24-hour
operations.
An official from another MTF stated that the MTF used 24 personnel to staff a COVID-19 testing and
vaccination tent from September 1, 2020, through July 31, 2022, which pulled their personnel away
from their normal duties for a total of 16,776 personnel days. The MTF officials also cited contact
tracing, a process to identify people that came in close contact with a person infected by COVID-19,
as a task that removed the MTF personnel from their normal duties. The MTF officials stated it was
a significant administrative burden during the pandemic because contact tracing was not the MTF’s
responsibility before the pandemic.
Further, an MTF official stated COVID-19 protocols such as quarantining and travel restrictions
prevented personnel from reporting to work, resulting in shortages of health care personnel. For
example, the MTF official stated that at one point during the pandemic, 25 nurses could not report
to work because of COVID-19 exposure and that the MTF had to follow travel policies requiring staff
to quarantine for 14 days on both the beginning and end of leave.
Hiring Timelines
The MTF officials reported that the hiring process was very long, taking 6 months or longer
because of security and credential checks, time to obtain an identification badge, or overseas
screening requirements, which was made worse by the pandemic.17 In April 2022, the DOD OIG
reported that at one MTF, the earliest it could complete a hiring action before the pandemic was
7 months, but during the pandemic it took 12 months.18 An official from another MTF stated that
during the pandemic it took the MTF 24 months to hire a medical technician and an official at
another MTF stated that they lost multiple nursing applicants because of the amount of time it
took for credentialing checks. An MTF official at an MTF located overseas stated they had at least
six candidates in FY 2022 that withdrew from the process because of the length of the security
clearance process. Additionally, officials at one MTF stated that no one was working in-person at
the identification card office to process common access cards during the height of the pandemic,
delaying the onboarding process for new personnel.
The Acting Deputy Commander of Quality and Safety from one MTF explained that they worked in
the private sector for 19 years and could hire nurses and have them on board, on average, within
two weeks. They explained that the MTF had four people at its last orientation, and it took the MTF
6 months to get each candidate on board after they were selected for their positions.
Limited Labor Pool
The MTF officials stated that there are shortages of health care personnel because there is a
limited labor pool to recruit from because of worldwide shortages of health care providers. Officials
from one MTF stated the ability of the contractor to provide staff was affected by a depleted pool

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DOJ
VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
of personnel who were taking advantage of travel opportunities for more money in other parts of
the country, while officials from another MTF stated that there was a limited number of qualified
applicants in their remote area.
At another MTF, a contractor responded to a contract discrepancy report stating that because the
contract was written before the pandemic, the contractor would not be able to fill the contracted
positions without a pay rate increase.19 According to the contractor, the mental health workers were
demanding higher salaries because there was a shortage of mental health workers, which was
worsened by the pandemic.
Mission Support
The MTF officials supported various COVID-19 and worldwide missions, such as Operation Allies
Welcome, and providing support for additional personnel in support of Ukraine, during the
pandemic, which the MTF officials stated created additional personnel shortages.20 For example,
the Federal Emergency Management Agency requested assistance for the civilian hospitals
throughout the United States, and the Government provided support through the Defense Support
of Civil Authorities missions. These missions assigned health care personnel from the MTFs to
assist civilian facilities in support of the nation’s pandemic response efforts. For example, an official
from one MTF stated that 300 military personnel from their MTF left on the U.S. Naval Ship Mercy in
support of the Defense Support of Civil Authorities mission, which provided medical support in Los
Angeles, CA, which was significantly affected by the pandemic. According to the MTF officials, this
required the remaining providers to perform additional work and work additional hours.
An official at another MTF stated that the MTF’s intensive care unit and medical surgical unit was
significantly impacted when the MTF needed to send 43 of its nurses to support the U.S. Naval
Ship Comfort. Additionally, because of the increased operations with Ukraine and Russia, an
official from one overseas MTF stated that the MTF personnel provided audiology, optometry, and
dental services at the pier to support the ships and other operational forces who were not enrolled
beneficiaries in their area.
The MTF officials have the ability to request temporary backfills from the Service Medical
Commands or the DHA when there are personnel shortages or personnel are pulled to support
missions outside the MTF. However, according to the MTF and Service Medical Command
personnel, the MTFs received very few to no replacements for the Service members supporting the
Defense Support of Civil Authorities and worldwide missions because all of the MTFs and Services
were strained during the pandemic. An official from one Service Medical Command stated that
although their Services could provide the MTFs with replacement Service members for 2 months,
the Services were less prone to approve a support request if it would create a shortage problem at
another site.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Federal and DOD-Imposed Restrictions
The MTF officials reported that federal and DOD-imposed restrictions contributed to shortages
of health care personnel at the MTFs during the pandemic. The MTF officials explained that
experience requirements for registered nurses (RN) hindered the MTFs’ ability to hire. The DOD
uses OPM’s requirements that require the MTFs to hire an RN at the GS-5 level if the applicant
has a bachelor’s degree with no nursing experience or has a diploma or associate degree in
professional nursing with 1 year of professional nursing experience. However, while RNs can be
hired without 1 year of experience at the GS-5 level, an official at one MTF commented that it was
an ineffective and nonsensical process because an RN with 1 year of experience or more, can be
hired at the MTF as a GS-11, or six grades above what the DOD offers RNs that do not meet the
experience requirement. Further, an MTF official stated that a licensed practical nurse, a position
that requires less education than an RN, are rated at the MTF as a GS-6, or one level above the
grade that the DOD hires its RNs who do not meet the 1-year experience requirement. The DOD
MHS is noncompetitive because of the low pay, hindering DOD’s ability to compete for nursing
candidates.
The MTF officials also mentioned that active duty members retiring from Service must wait 180
days before beginning work in a civilian position at the MTFs. Specifically, section 3326, title 5,
United States Code, requires Service members to wait 180 days before being appointed to a civilian
position, even though the Service member is already familiar with the MTF’s policies and systems
and would not require as much training as someone newly-hired to the MTF. An MTF official stated
that they would prefer to continue working as a civilian; however, they could not wait 180 days to be
considered for employment and, therefore, would leave the MTF to work for the private sector after
retirement where they can find a job more quickly. Although there is a waiver process to exempt
retired Service members from the 180-day waiting period, an MTF official reported that the process
to obtain a waiver and be onboarded was still over 120 days.
Officials at two MTFs located outside the continental United States stated that civilian employees
are limited in how long they can work in overseas assignments, affecting their ability to hire and
retain health care personnel. The MTF officials stated that civilian personnel would like the option
to extend beyond 5 years at overseas locations. DOD Instruction 1400.25 limits civilian employment
in foreign areas to five continuous years but allows the Head of the DOD component to grant
extensions in 2-year increments, with the support of a documented business case analysis.21
However, an MTF official explained that the process to extend civilian assignments takes too long
because the MTF must demonstrate it has actively recruited for the position with no successful
hires before the end of the individual’s 5-year appointment.
The DOD OIG plans to further address the causes above with recommendations in a separate DOD
OIG report.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Impacts of Shortages of Health Care Personnel
The MTF officials from the 24 MTFs we interviewed reported impacts to the MTF’s patients, the
availability of specialty care, the health care personnel, and Military readiness because of health
care personnel shortages during the pandemic. See Exhibit 4 for the number of MTFs that had
personnel report that they experienced these impacts.
Exhibit 4: Number of MTFs That Reported the Top Impacts of Health Care Personnel Shortages
Patient Impacts
Health Care
Personnel Impacts
MTF and Product
Line Impacts
Military Readiness
Impacts
24
24
13
24
Source: DOD OIG interviews with officials from sample of MTFs, August through September 2022.
Note: Totals represent the number of MTFs out of 24 that had officials reporting the impact.
Patient Impacts
Officials from all 24 MTFs cited impacts to patient care because of health care personnel shortages,
such as decreased patient access to care, satisfaction, and preventative screenings or routine
maintenance care for patients. For access to care, an official from one MTF explained that a
patient’s ability to get an appointment in the MTF during the pandemic decreased anywhere from
10 to 50 percent, which lengthened the time for beneficiaries to receive care. According to the
MHS website, the access to care metrics for another MTF, with a benchmark of 7 days for routine
appointments, jumped from 2.6 days in November 2020 to 10.2 days in November 2022.
Health care personnel vacancies at the MTFs outside the continental United States can lead to
reduced or no specialty services for beneficiaries, where the civilian network is already limited or
nonexistent. For example, an official at one overseas MTF stated that there are no behavioral health
civilian network services for children in their area. The Child and Family Behavioral Health Service

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VHA
HHS
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  U.S. Department of Defense
DOD
at the MTF closed in March 2022 because the MTF had difficulty hiring behavioral health personnel
and lost behavioral health personnel whose extension requests were denied, as well as usage of
behavioral health care increased. Additionally, all of the licensed clinical social workers were pulled
from the behavioral health program to support the active duty clinic, resulting in no behavioral
health services for children. The MTF official further stated that continued closure of the behavioral
health network services for beneficiaries would increase the number of denials for the Exceptional
Family Member Program, which would decrease the number of Service members eligible to be
assigned to locations outside of the continental United States.22
The MTF officials also stated that patient satisfaction decreased during the pandemic. According
to one MTF’s patient satisfaction report, the scores declined during the pandemic, every year from
2020 through 2022. Specifically, in 2020, patients rated the ease of making an appointment at
one MTF at 70.7, with a MHS benchmark of 74.0.23 However, in 2022, patients rated that same
category for the MTF approximately 14 percent lower at 56.3, well below the MHS benchmark of
78.2 for that year.
Officials from another MTF stated they had both sentinel and adverse events that were reported
to the DHA Patient Safety Office due to low staffing or increased workload for staff.24 Based on a
comprehensive systematic analysis provided by the Patient Safety Program Manager, a pediatric
patient had significant delays with diagnosis because of personnel shortages. Specifically, during
the patient’s need for care, four of five pediatricians from the MTF were deployed for missions in
support of the pandemic, leaving one dedicated pediatrician and one family medicine provider with
pediatric training to oversee the entire child dependent population at the MTF. As a result, pediatric
operations were limited for 2 months, including deferred wellness visits, and the patient was seen
virtually, which led to a delay in diagnosis and treatment for a metastasized tumor.
Additionally, the Patient Safety Program Manager provided an example of a patient that committed
suicide within 72 hours of being seen in the emergency department that, according to the MTF
officials, had low staffing. The MTF officials explained that the patient was seen by a provider who
was unaware of the patient’s history because the provider was temporarily assisting while the
MTF was experiencing personnel shortages. The MTF officials also stated that psychiatrists were
not evaluating patients in-person in the emergency department at that time because of pandemic
protocols. According to the comprehensive systematic analysis, the sentinel event was attributed to
various root causes, including task oversaturation for providers.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Health Care Personnel Impacts
Officials from all 24 MTFs stated that shortages of health care personnel during the pandemic
impacted the personnel remaining at the MTF, including increased work hours, decreased morale,
increased duties, and decreased access to medical cases that are necessary for providers to gain
or maintain skills. The MTF officials explained that because the DOD tasked health care personnel
for other missions or because the MTF had long-standing vacancies, the personnel left to work in
the MTF were required to work significantly more hours than normal. For example, an official at
one MTF stated that Service members were working between 80 to 100 hours per week and, as
a result, some providers were treated for mental health issues because of burnout. An official at
another MTF stated that health care personnel were tasked for Defense Support of Civil Authorities
missions resulting in the remaining personnel working up to 120 hours in a 2-week period.
According to an overtime report for civilian personnel working at one MTF, overtime hours increased
almost 50 percent from 2019 through 2020 when the pandemic first began, increasing from 1,233
hours in 2019 to 1,816 hours in 2020. The MTF officials also stated that pay for increased overtime
hours comes from their budget and limits their ability to hire additional personnel. Further, the MTF
officials reported an increased use of behavioral health providers to treat the health care providers
who were seeking care for their own mental health because of burnout.
Additionally, the MTF officials stated that performing duties outside of their normal job function
was required because of shortages in health care personnel. For example, the MTF officials
stated that providers checked patients in, recorded patient vitals, and cleaned their own areas
because of shortages in support personnel, such as medical support assistance and housekeeping
personnel. An official at another MTF stated that an enlisted pharmacy technician performed the
MTF’s emergency management functions, a role normally performed by a GS-13 civilian position, in
addition to their pharmacy duties.
The MTF officials also discussed how shortages in health care personnel and reduced elective
procedures decreased their ability to gain and maintain experience and skills. Specifically,
personnel were not able to get the experience they needed to maintain their knowledge, skills,
and abilities because the MTFs were not able to bring in a high volume of medical cases to learn
from, and personnel were tasked to conduct tasks, such as overseas screening assignments or
periodic health assessments as a result of the pandemic and health care personnel shortages. The
MTF officials explained that they had to send some providers to civilian hospitals to maintain their
knowledge, skills, and abilities.
The MTF officials also had concerns with tasking faculty who oversee the graduate medical
education program to provide mission support. According to the MTF officials, a majority of the
MTF’s inpatients were cared for by the graduate medical education students who were medical
residents under the supervision of the MTF faculty that have specific qualifications. Because faculty-
to-student ratios must be maintained for the graduate medical education students to provide care,
when the supervising faculty were tasked to support missions outside of the MTF, the MTF had to

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
reduce the number of patients who could be admitted and cared for safely, which also reduced the
number of cases from which the residents could learn.
The MTF and Product Service Impacts
Officials from all 24 MTFs stated that health care personnel shortages impacted health care
services that were available in the MTF. Specifically, the MTF officials reported that their MTFs had
to:
•	 reduce or suspend some specialty services and defer patients to the civilian network,
•	 decrease the number of patient visits, and
•	 reduce the capacity of inpatients because of the decreased health care personnel available
during the pandemic.
For example, an official from one MTF stated that because of staffing shortages the MTF’s inpatient
“bed space” (capacity) decreased by 30 percent, outpatient access to care decreased by 50
percent, and the emergency room unit was downgraded to an emergent care clinic. The MTF
officials stated that “shutting off” (suspending) or reducing services because of staffing issues
resulted in diverting more health care services to the civilian network. For example, an official from
one MTF stated that demand for mental health increased dramatically during the pandemic, and
that because of staffing issues, most referrals were diverted to the civilian network. The MTF official
provided data from the Composite Health Care System and MHS GENESIS showing that in 2020,
the MTF had 2,600 mental health referrals, and the MTF was able to treat approximately 2,500 (95
percent) patients, only diverting less than 125 patients to the civilian network. However, in 2021
and 2022, mental health referrals increased significantly to 6,240 and 8,576, respectively, and
because of the pandemic and staffing losses, the MTF was only able to treat approximately 1,200
(less than 20 percent) of the referred patients, diverting the remaining 80 to 85 percent of patients
to the civilian network.
An official from another MTF stated that their MTF was authorized 41 enlisted laboratory
technicians but explained that they would be down to only 4 technicians in February 2023. The
official stated that pharmacy and laboratory operations were staffed 50 percent lower than they
were 4 years ago so the MTF had to reduce laboratory and pharmacy services. The MTF officials
also expressed concerns for increased risks to patient safety in the MTF. For example, one MTF
official stated that not having experienced nurses to train new nurses led to safety concerns for
patients. The senior enlisted leader at another MTF stated that the enlisted health care personnel
and providers were exhausted from all of the work because of the shortages of personnel, and they
were worried that it was only a matter of time before a provider would “miss something.”

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Military Readiness Impacts
Officials from 13 MTFs reported operational force readiness and deployment delays because of
health care personnel shortages. According to an official from one MTF, an MTF lab processed
COVID-19 testing requirements in direct support of their operational forces. However, because of
the limited availability of personnel in the MTF lab and the limited availability of lab services in the
network to meet COVID-19 testing requirements, the operational force did not deploy as scheduled.
An official at another MTF stated that because of shortages in civilian lab technicians, active duty
lab technicians had to work 12-hour shifts, 6 days per week, to test Service members in basic
training for COVID-19. According to the Deputy Commander for Clinical Services, the laboratory
technicians became burnt out and were provided mental health treatment because of stress. An
MTF official stated that the MTF Commander cut back on testing and informed the operational
commanders that the MTF would not be able to turn testing around fast enough for their Service
members to deploy for their missions.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Defense
DOD
Efforts to Recruit New Staff, Retain Existing Staff, and
Minimize Personnel Burnout During the Pandemic
The DOD has several monetary programs to recruit and retain health care personnel; however, the
MTF officials stated that even with monetary incentives, DOD compensation still could not compete
with the private sector and other federal agencies. Based on interviews, efforts to minimize burnout
varied by the MTF.
Recruitment Incentives
The DOD has several monetary programs to recruit health care personnel. See Table 2 for a list of
DOD recruitment incentives.
Table 2: DOD Recruitment Incentives
•
•
Surge
Contracts
Contracts awarded by the MTFs with higher hourly wages to recruit personnel to
temporarily assist the MTFs during the height of the pandemic.
Direct Hire
Authority
DOD’s ability to recruit and appoint qualified persons directly, without competitive
procedures, for occupations designated by the Secretary of Defense as a shortage
category, or critical need occupation, including psychologists, physicians, and nurses.a
This authority was delegated to the Secretaries of the Military Departments, Directors of
the Defense agencies, and Directors of DOD field activities.
Loan
Repayment
The federal student loan repayment program permits the DHA to repay federally insured
student loans. Active Duty Health Professions Loan Repayment Program (ADHPLRP)
pays for the degrees of commissioned officers qualified in health professions.
Monetary
Bonus
The DHA may pay a recruitment incentive if an employee is newly appointed to a
position that is difficult to fill, and the employee is not receiving incentive payments from
a service agreement required for another incentive during the period of employment.
Medical officers are entitled to a signing bonus if they have graduated from an
accredited school in a health care profession, are qualified for appointment as a
commissioned officer, and have been honorably discharged for at least 24 months, if a
former health professions officer.b
Source: DOD OIG review of the USD (P&R) Memorandums, DOD Instructions, DHA Instructions, and interviews with officials from
sample of the MTFs.
a.	 USD (P&R) Memorandum, Expansion of Direct Hire Authority for Certain Personnel of the Department of Defense, October 15,
2021.
b.	 A health care professional officer is an officer designated as a medical officer, dental officer, veterinary officer, medical service
officer or biomedical sciences officer, medical specialist, or a nurse.

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HHS
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  U.S. Department of Defense
DOD
Retention Incentives
The DOD has several incentives to retain health care personnel. See Table 3 for a list of DOD
retention incentives.
Table 3: DOD Retention Incentives
•
•
Monetary Bonus
Authorized if the position is difficult to fill or the employee has unique qualifications,
there is a high risk that the employee would leave the federal Service; the employee
is rated at least “Fully Successful,” and the employee is a GS employee for at least
1 year. The bonus is up to 25 percent of the employee’s salary and is paid from the
MTF’s budget. Medical officers are entitled to a multi-year retention bonus if they
remain on active duty for 2 years or more after any other commitment.
Student Loan
Repayment
The federal student loan repayment program permits the DHA to repay federally
insured student loans.
Special Salary Pay
Tables
The MTFs can submit a packet through the DHA to the OPM to request a special
salary rate to combat pay inequities. Physicians and dentists are on a “GP” pay
scale and can receive title 38 market pay instead of locality pay.a Medical officers
are entitled to a special rate based on rank and experience, including board
certification.
Recognition
Set aside time for employee appreciation, appraisal bonuses, time-off awards, early
departure, command coins, contractor letters of appreciation.
Flexibility
Offer telework, virtual telehealth, remote opportunities, and alternative work
schedules where available.
Source: The DOD OIG review of the DHA Instructions and interviews with officials from sample of the MTFs.
a.	 GP is a pay plan code under the General Schedule pay system and includes physicians and dentists who receive title 38 market
pay instead of locality pay.

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VHA
HHS
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  U.S. Department of Defense
DOD
Efforts to Minimize Burnout
The MTFs and the DHA have developed ways to address and avoid staff burnout. See Table 4 for a
list of efforts used by the MTFs to minimize burnout.
Table 4: MTF Efforts to Minimize Burnout
•
•
Mental Health
Making counseling and behavior health sessions, meditation spaces, and chaplain
services available to health care personnel.
Time-off
Encouraging the use of leave (except during the height of the pandemic when leave
was denied because of mission requirements).
Leadership Efforts
Leadership providing flexibility for providers with their patient scheduling, including
administrative time or down time for providers to catch up on their workload.
Resiliency
Training
Training to help staff learn ways to relax and deal with burnout.
Ready, Reliable
Carea
The DHA’s campaign to leverage the entire workforce. Whether personnel are in
clinical or administrative roles, all personnel are responsible for helping.
Source: DOD OIG review of the DHA Instructions and interviews with officials from sample of the MTFs.
a.	 Ready, Reliable Care is guidance that is not yet finalized or published, but is a DHA initiative to standardize care across the MHS
to help reduce burnout.

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DOD
DOJ
VHA
HHS
U.S. Department
of Justice (DOJ)
The Federal Bureau of Prisons (BOP) is responsible for the safekeeping, care, and subsistence
of federal offenders.  As part of this mission, the BOP provides medical care to the over 134,000
federal inmates and pre-trial detainees housed in BOP-managed institutions.25 According to the
BOP, it aims to effectively deliver medically necessary health care to inmates in accordance with
proven standards of care without compromising public safety concerns inherent to the BOP’s overall
mission. The BOP uses a medical care level classification system to help match inmate health
needs with institutions that can meet those needs. The classifications range from Care Level 1 for
generally healthy inmates to Care Level 4 for inmates who require enhanced medical services or
limited inpatient care. Institution care levels are based on the clinical capabilities and resources of
the institution and the surrounding community.
Each of the BOP’s 121 institutions operates an on-site health services unit that provides urgent
and routine health care services. Additionally, each institution has procedures to handle medical
emergencies during hours that health care providers are not on site. Seven of the BOP’s 121
institutions are medical centers, which offer 24-hour inpatient care units and a variety of
specialized services, such as dialysis, oncology, prosthetics and orthotics, and dementia care.
As of March 2022, a total of 2,998 personnel, worked in BOP’s institution health services units,
including 2,478 BOP-employed civil service employees and 520 commissioned officers of the
U.S. Public Health Service.26 The number and type of health services positions authorized at an
institution vary based on the institution care level, population size, and special medical missions
of the institution. In Table 1 below we present the nine most common health services positions at
BOP institutions. Together, these position types account for about 84 percent of all institution-based
health services positions within the BOP.27 Registered nurse positions make up almost one-third of
all institution health services positions.

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DOJ
Table 1: Most Common Health Services Positions at BOP Institutions
Position Type
General Description of Responsibilities
% of Health
Services
Positionsa
Clinical
Registered
Nurse
Delivers physician-ordered care, performs nursing assessments and procedures,
administers medications at designated pill lines, conducts triage and clinics,
performs intake screening of newly admitted inmates, and delivers emergency
nursing care.
32%
Mid-level
Practitioner
Certified nurse practitioners, certified physician assistants, and international medical
graduates who assess, diagnose, and treat medical conditions under the license of
a physician. Conducts physical examinations, emergency care, chronic care clinic
evaluations, and preventive health care.
12%
Medical
Officer
Physicians with the authority to assess, diagnose, treat, and educate patients and
to and prescribe medications. Performs physical examinations, orders diagnostic
testing, provides treatment and prescribes medications as required, and refers
patients to consultant specialists or community hospitals when necessary. Provides
clinical oversight for mid-level practitioners and other clinical personnel.
8%
Health
Aid and
Technician
Includes paramedic positions (manages emergencies and injuries, administers
medications at designated pill lines, and performs intake screening and clinic duties
during off-shifts) and medication technician positions (administers medications at pill
lines, prepares medications, assists with pharmacy inventory.)
7%
Pharmacist
Adjudicates medication orders, dispenses medication, counsels and educates staff
and patients, and monitors the safe and appropriate use of medications.
6%
Dental Officer
Responsible for the full range of dental care provided to inmates, including
prevention, diagnosis and treatment of diseases, injury, and deformities of the
mouth.
5%
Nonclinical
Health
Services
Administrator
Functions as the department head for the health services units. Plans, directs, and
manages the health services unit operations.
6%
Health
Information
Specialist
Manages electronic and paper medical records and collects, stores, retrieves, and
protects the confidentiality of health information.
5%
Health
Services
Assistant
Schedules appointments; coordinates external medical trips; files medical
information; manages correspondence, reports, and purchase cards.
5%
Source: DOJ OIG summary of BOP guidance and data.
a.	 Total does not equal the 84 percent reported above because of rounding.

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  U.S. Department of Justice
DOJ
Impact of COVID-19 on the BOP
There have been over 60,000 inmate cases of COVID-19 since March 2020, according to the BOP’s
2023 Congressional Budget Submission. The pandemic created challenges for the BOP as it worked
to prevent and manage the spread of the disease in its institutions. The CDC noted that, due to the
congregate nature of correctional environments, “the risk of COVID-19 transmission is higher in
these settings compared with the general population.” The BOP implemented a series of modified
operations intended to help mitigate the spread of COVID-19 inside BOP facilities, including
movement restrictions, limiting capacity for group activities, suspending in-person social visiting,
and enhanced cleaning procedures.
The pandemic increased the workload for BOP institution health services personnel.  COVID-19
symptom screening, testing, and monitoring and caring for inmates in quarantine and medical
isolation added significant responsibilities to the BOP’s health services units. Modified operations
put in place to help manage the pandemic also increased workloads. For example, as a result of
restrictions on inmate movement, some institutions conducted sick calls, that is the process by
which inmates request and receive routine or preventative medical care, and delivered medication
in multiple discrete housing units that are located across large compounds. This is in contrast to the
standard practice wherein large numbers of inmates from multiple housing units could report to a
single, centralized location to receive those services.
Further, some modified operations directly affected health care delivery during the pandemic. For
example, at some institutions where operations were severely disrupted due to the pandemic the
BOP postponed routine services in order to focus on urgent health care needs, postponed routine
and elective external medical trips, and suspended routine dental care at institutions where there
was widespread COVID-19 transmission.
Scope of DOJ OIG Review
This review provides information on BOP civil service employees and commissioned officers of the
U.S. Public Health Service who work in the health services units at BOP institutions. Although there
are 121 BOP-managed institutions, the BOP considers the federal correctional complexes, in which
multiple institutions are co-located, to be a single institution when reporting staffing data instead of
counting each constituent facility separately. Therefore, the total number of facilities described in
the March 2022 BOP staffing data used in this review is 97. When looking at only clinical positions,
the total facilities decreases to 96 because the 97th facility, FCC Beaumont uses only contract
clinical staff.
This review does not include BOP’s psychology staff because they are not part of the BOP’s health
services units. Additionally, this review does not include information about contract health care
providers who may provide specialized on-site care at BOP institutions, cover institution vacancies

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  U.S. Department of Justice
DOJ
on a short-term basis, or deliver care to BOP inmates at community facilities not operated by the
BOP. (See Appendix B: BOP for DOJ OIG’s methodology.)
Health Care Personnel Shortages Before and During
the Pandemic
Health services personnel shortages have been a long-standing challenge for the BOP.  As of
September 2014, health services positions at BOP institutions were only 83 percent filled overall,
according to a DOJ OIG report on the BOP’s medical staffing challenges, published in March 2016.28
As shown in Exhibit 1 below, from March 2019 through March 2022, the BOP experienced similar
fill rates for health services personnel positions, both before and during the pandemic. Although the
number of authorized health services positions, or total positions BOP could fill, varies by year, the
BOP has consistently struggled to fill health services positions at its institutions.
Exhibit 1: Percent of Institution Health Services Positions Filled
March 2019
March 2020
March 2021
March 2022
2,926
filled
(85%)
3,459
authorized
3,038
filled
(82%)
3,719
authorized
3,170
filled
(85%)
3,718
authorized
2,998
filled
(82%)
3,642
authorized
Source: DOJ OIG analysis of BOP data.
From mid-2019 through mid-2021, the BOP made progress toward addressing its shortages of
health services personnel. Despite the pandemic, the BOP increased the number of filled health
services positions during this time, as shown in Exhibit 2 below. However, based on available data,
the overall fill rate for institution health services positions never exceeded 85 percent, and the fill
rate declined from August 2021 through at least July 2022. The decrease in health services staff
appears to be driven both by a decrease in hiring and an increase in resignations.

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  U.S. Department of Justice
DOJ
Exhibit 2: Net Increases and Decreases in Health Services Staffing, by Pay Period, January 2019
Through July 2022
2019
2020
2021
2022
Pay Period 17
(August 2021)
Net Health Services Staff
0
50
100
150
200
250
300
350
400
450
-50
Source: DOJ OIG analysis of BOP data.
Note: Each rectangle represents the net increase or decrease in staffing for the pay period. There are 26 pay periods each calendar
year.
During this period, the staffing levels of individual institutions ranged from fully staffed down to
only 37 percent staffed. Regional Health Services Administrators (HSA) generally identified a fill
rate of 80 to 85 percent for health services positions as a threshold of concern, although some
emphasized that even institutions with a higher overall filled percentage could still have specific
critical vacancies that drastically hinder health services operations. There are often only one to two
authorized positions for each type of position, especially at smaller institutions, which means that a
single dental officer vacancy, for example, could render an institution unable to offer on-site dental
care. Further, clinical staff who provide direct inmate care often have specialized roles and licensing
requirements so other health service staff often cannot cover the responsibilities of those vacant
positions. While clinical staff can cover administrative tasks, nonclinical staff cannot assist with
tasks such as medication delivery. As shown in Exhibit 3 below, BOP health care staffing has been
consistently lower on the clinical side.

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DOJ
Exhibit 3: Fill Rates for Clinical and Nonclinical Health Services Positions
March
2019
March
2020
March
2021
March
2022
Clinical
Nonclinical
0
0
400
800
500
1,000
1,500
2,000
2,500
3,000
(83%)
(81%)
(84%)
(81%)
(89%)
(86%)
(90%)
(87%)
Source: DOJ OIG analysis of BOP data.
Regional HSAs we interviewed also identified specific clinical positions that they have found to be
particularly challenging to fill, including medical officers (physicians), mid-level practitioners (such
as nurse practitioners and physician assistants), and nurses. (See Table 1 above for descriptions
of these roles.) These challenges are apparent in our analysis of BOP’s staffing data for March
2022. As shown in Exhibit 4 below, 85 of the 96 (89 percent) BOP facilities had one or more clinical
position vacancies. These shortages are especially concerning for the 13 facilities that did not have
a medical officer on staff as of March 2022. The responsibilities of medical officers (physicians)
generally include diagnosing and treating patients, prescribing medications, referring patients for
specialist care, and overseeing other clinicians. Although direct patient care responsibilities can
be covered by mid-level practitioners, these types of critical vacancies may require the BOP to
bring in staff from other locations on temporary duty assignments, or to use short term emergency
contracts to fill the gaps.

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Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Exhibit 4: Number of Facilities with Vacancies in Select Clinical Positions, March 2022
One or more vacancies
All positions vacant
All positions filled
All clinical
positions
Medical
officers
Mid-level
practitioners
Nurses
11
49
13
34
43
48
30
64
2
85
3
Source: DOJ OIG analysis of BOP data.
Note: There are 96 facilities represented in this data because the BOP’s staffing data considers all institutions within a federal
correctional complex together. The 97th facility, FCC Beaumont, is not included in this data because it relies solely on contracted
clinical staff. The facility total for mid-level practitioners is 94 because there were two additional facilities without authorized mid-
level practitioner positions in March 2022.
Additional analysis of the positions that regional HSAs identified as hard to fill reveals that
despite an increase in staffing between 2020 and 2021, staffing fill rates for nurses and mid-
level practitioners decreased between 2021 and 2022. See Table 2 below. In particular, in March
2022, the filled rate for nurses fell below early pandemic levels. At that time, 69 percent (66 of 96
facilities) had vacant nurse positions, as shown in Exhibit 4. With respect to filled medical officer
positions across BOP institutions, the percentage remained critically low during the pandemic.
On top of these shortages, the current number of authorized clinical positions may not reflect the
actual health services staffing needs at institutions, according to several Regional Health Services
Administrators (HSA). One Regional HSA we interviewed said that the number of nurses authorized
for his region is not sufficient to meet inmate health care demand.  Therefore, BOP position
shortages may be even more critical than the data shows.
Table 2: Fill Rates for the BOP’s 3 Most Common Clinical Positions During the Pandemic
Position
March 2020
March 2021
March 2022
Medical Officers
68%
69%
69%
Mid-Level Practitioners
76%
82%
80%
Nurses
84%
87%
82%
Source: DOJ OIG analysis of BOP data.

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  U.S. Department of Justice
DOJ
Contributing Factors That Led to Shortages of Health
Care Personnel
Although it is not reflected in the overall staffing data, staff illnesses contributed to health services
staffing shortages during the pandemic as health services personnel contracted COVID-19 and
needed to take sick leave to recover. For example, FCI Milan reported that 50 percent of its medical
staff contracted COVID-19 and had to take sick leave in the first week of its first COVID-19 outbreak
in April 2020.29 Overall, FCI Milan reported that 75 percent of its health services staff contracted
COVID-19 and had to take sick leave at some point during that outbreak. As a result, one Mid-level
Practitioner reported that they and another clinical staff member worked alone for weeks, taking on
the responsibilities of the other staff on sick leave.
Additionally, we identified numerous factors that impair the BOP’s ability to recruit and retain health
services personnel, including several challenges the BOP has reported as longstanding issues, as
well as additional reasons identified by regional HSA and human resources staff we interviewed:
Limited labor pool: The BOP needs mostly primary care physicians, but medical school
graduates increasingly pursue medical specialty fields over primary care medicine.
Location: Many BOP institutions are located in rural areas, and the BOP has found it challenging
to recruit health care professionals in these areas because of limited availability locally and
difficulty recruiting these professionals from outside the area. Conversely, in urban areas, the
BOP faces competition with other health care employers.
Noncompetitive pay: In addition to the location-driven challenges described above, interviewees
identified further hiring and retention issues in urban locations due to higher cost of living in
urban areas for which BOP salaries may not be commensurate (equal or adequate).
Some federal agencies have title 38 authority, which allows them to offer higher salaries across
all licensed medical disciplines. While the BOP currently has title 38 authorities for three
disciplines – psychiatrists, physicians, and dentists – it cannot compete with title 38 salaries
offered for other disciplines.
During the pandemic, health care professionals, especially nurses, were in high demand and
often were offered higher-than-usual pay rates that the BOP could not match.
Hiring process:  Aspects of the hiring process can be challenging for health care recruiting.
Specifically, the federal hiring process is different than what health care professionals may be
used to in the private sector, and it can be time consuming for both applicants and the BOP.
Nuances in the job postings and application process may prevent applicants from applying to or

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
being selected for available job opportunities. Additionally, not filling vacancies fast enough can
lead to a “domino effect” of resignations as workloads are distributed to remaining staff.
Limited promotion opportunities:  Limited opportunities for career advancement in some
health services positions can result in clinical personnel moving into nonclinical supervisory
roles and experienced nonclinical personnel leaving to take other opportunities that would allow
them to qualify for supervisory roles in the future.
Challenges of the job: Working in the correctional health care setting may not be a preferred
workplace for everyone. The correctional setting has additional stressors and responsibilities
that health care workers do not have to contend with in other settings.  For example, a regional
HSA stated that nurses in the community did not have the same requirements as employees
who work in correctional facilities, such as requirements to wear stab vests, carry a “big wad
of keys,” or carry oleoresin capsicum (pepper) spray. Because of these added challenges, one
interviewee stated that the BOP’s total compensation may need to exceed what other employers
are offering to attract and retain health care staff.
Available schedules: 40 health services exit survey respondents mentioned that having
a different schedule would have allowed them to stay with the BOP, including compressed
schedules, part-time options, and telework.
Impacts of Shortages of Health Care Personnel
Shortages of health care personnel had effects on inmate care, as well as personal and
professional effects on health care staff during the pandemic.  Staffing shortages also had financial
impacts on the BOP, as staff worked overtime to manage increased workloads.
Patient Impacts
Decreased Patient Satisfaction
According to an April 2021 survey on federal inmates’ experiences during the pandemic, inmates
generally perceived that the quality of health care made available to them decreased during the
pandemic, particularly during restrictions of inmate movement through lockdowns that the BOP
implemented to prevent the spread of COVID-19.30 Specifically, an estimated 80 percent of inmates
rated BOP’s provision of medical care as poor during pandemic lockdowns, compared to an
estimated 41 percent of inmates who described the provision of medical care as poor before the
pandemic.

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VHA
HHS
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  U.S. Department of Justice
DOJ
Delays in Routine and Preventative Care
As COVID-19 outbreaks disrupted normal operations at BOP institutions, health services units also
had to adjust their operations. BOP’s pandemic response plan recommended that, depending
on the COVID-19 level in the institution and the community, BOP institutions reduce or postpone
preventative health care services, postpone care for low priority health problems, and focus on life-
saving care.
At some institutions, health care staffing shortages affected the BOP’s ability to provide routine
medical care. For example, staff at the Metropolitan Detention Center Brooklyn reported that
severe staffing shortages resulted in challenges responding to sick call requests. Sick call wait-
times increased significantly as the institution received a much higher number of sick-calls due
to COVID-19. An official from the Metropolitan Detention Center Brooklyn reported that in late
September 2020, there were 160 inmate sick call requests dating back to early July 2020 that had
not been scheduled or completed. One regional HSA we interviewed reported that the region had
observed a backlog of nursing tasks during the pandemic; for instance, one of the institutions in
their region had a backlog of 170 electrocardiograms.
Increase in Telehealth Use
During the first year of the pandemic, the BOP expanded access to telehealth services, which
can help promote access to medical care generally, while also mitigating the risk of COVID-19
transmission. The proportion of inmates in BOP-operated institutions using telehealth more than
doubled compared to the prior year. Telehealth services were used for both external visits delivered
by outside providers, as well as clinical encounters with internal providers. Psychiatry visits with
internal BOP providers were the leading type of telehealth visit for specialty care, accounting for
41 percent of specialty care visits.  For more information on the BOP’s use of telehealth during
the pandemic see the PRAC report Insights on Telehealth Use and Program Integrity Risks Across
Selected Health Care Programs During the Pandemic.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Health Care Personnel Impacts
Increased Workloads
The pandemic increased health services staff workloads as they handled large numbers of inmate
illnesses due to COVID-19, as well as took on new responsibilities including screening and testing
for COVID-19 and monitoring of quarantine and isolation units. Two regional HSAs noted that mass-
testing initiatives, in which entire housing units had to be tested for COVID-19, were extremely labor
intensive for health services staff.
In addition to the pandemic, health service staff workloads are also routinely increased due to
augmentation, which is the practice of assigning non-custody staff, such as teachers or health
care professionals, to temporarily assume the duties of a correctional officer. Regional HSAs that
we interviewed stated that clinical providers were often exempt from augmentation based on
institution-level agreements. However, one regional HSA emphasized that augmenting staff from
any health services role can cause work to accumulate.
We assessed augmentation hours and found that that BOP health services personnel worked over
11,300 augmentation hours during the first year of the pandemic. In Table 3 below, we provide
the augmentation hours for BOP’s health services personnel by pandemic year. Although total
augmentation hours for health services personnel were lower in the first year of the pandemic than
in other years, the practice still increased health services staff workloads during the pandemic,
as staff either needed to delay the completion of their regular responsibilities, or transfer them to
other health services staff, when asked to take on temporary correctional officer duties. The use
of augmentation was accompanied by a 56 percent increase in overtime hours, which we discuss
below.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Table 3: BOP Health Services Personnel Augmentation Hours by Pandemic Year
Pandemic Year
Augmentation
 Hours
Number of
 Employees
Before Pandemic (March 2019 - February 2020)
15,636
416
First Year of Pandemic (March 2020 - February 2021)
11,386
296
Second Year of Pandemic (March 2021 - February 2022)
11,877
315
Third Year of Pandemic (March 2022 – August 2022)
11,486a
307
Total
50,386b
659
Source: DOJ OIG analysis of BOP augmentation hours.
a.	 This sum represents a partial year. At the time of our data request, the last date available for overtime data was August 2022.
b.	 Total does not equal the actual sum because of rounding.
Additionally, we found that augmentation is not standardized across the health services
occupational series at the BOP. Of the 50,386 augmentation hours worked by health services staff
from March 2019 through August 2022, 38 percent of those hours were performed by medical
records technicians, 10 percent by health technicians, and 6 percent by assistant health service
administrators.
Well-Being
Regional HSAs we interviewed described the experience of health services personnel during the
pandemic a variety of ways, including “arduous” and “stressful.” They also said that health services
personnel were “severely overworked” and often “scared” and “exhausted.” In response to a 2021
survey of institution staff, 75 percent of health services personnel respondents (583 of 775)
reported experiencing increased stress or anxiety at work because of the pandemic, and 34 percent
of respondents (262 of 775) reported considering leaving the BOP because of the pandemic.31

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Financial Impacts
Overtime Costs
One of the tools that the BOP uses to supplement shortages of personnel is authorizing BOP
employees to work overtime. We assessed BOP’s overtime spending and found that that BOP health
services personnel worked over 314,000 overtime hours during the first year of the pandemic, at
a cost of $15 million, which represented an increase of 56 percent and 64 percent, respectively,
compared with the overtime hours and costs in the year before the pandemic. In Table 4 below, we
provide the overtime hours and costs for BOP’s health services personnel by year of the pandemic.
Table 4: BOP Health Services Personnel Overtime Hours and Costs by Pandemic Year
Pandemic Year
Overtime Hours
Overtime Costs
Before Pandemic (March 2019 - February 2020)
201,007
 $9,164,471
First Year of Pandemic (March 2020 - February 2021)
314,498
 $15,044,010
Second Year of Pandemic (March 2021 - February 2022)
198,299
 $9,419,537
Third Year of Pandemic (March 2022 - October 2022)a
136,245
 $6,577,194
Total
850,049
 $40,205,212
Source: DOJ OIG analysis of BOP overtime data.
a.	 At the time of our data request, the last date available for overtime data was October 2022.
In addition, we found that overtime is not standardized across occupational series at the BOP;
rather, a small number of position types account for a large percentage of health services overtime.
For example, nurses accounted for nearly 55 percent of all overtime hours worked by BOP health
services personnel from March 2019 through October 2022, which we calculated to be the
equivalent of approximately 61 full time positions per year.

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VHA
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  U.S. Department of Justice
DOJ
Efforts to Recruit New Staff, Retain Existing Staff, and
Minimize Personnel Burnout During the Pandemic
From January 1, 2019, through December 31, 2021, the BOP spent about $27.8 million in incentive
payments to over 1,300 health services employees in an effort to attract and retain its medical
personnel.  For several decades, BOP policy has authorized the use of recruitment, relocation,
and retention incentives either to encourage prospective employees to accept a position or retain
current employees with high or unique qualifications who would likely leave BOP without an
additional incentive to stay. The BOP increased its use of incentive payments in 2020, during the
pandemic.
Recruitment Initiative
From April 2020 through January 2021, the BOP ran an advertising and marketing campaign to hire
health services staff through expanded recruitment efforts. This hiring campaign represented an
attempt to rebrand and market the BOP for new recruits and included the use of online recruiting,
social media, and web analytics. For example, the BOP held live social media events geared toward
the recruitment of nurses to reach wider audiences and drive applicants to the BOP application
portal. Data on incoming BOP employees indicates that the BOP hired more new health service staff
in 2020 than it did in either 2019 or 2021.
Recruitment Incentives
The BOP can offer monetary and non-monetary incentives, which can help recruit health care
personnel. Several of BOP’s regional HSAs and regional human resources administrators stated
that the most effective recruitment incentives involved monetary compensation. Specific incentives
they listed included recruitment bonuses, relocation incentives, student loan repayments, salary
above the minimum step of the candidates qualifying grade, and use of title 38 pay. In Table 5
below, we provide additional detail on these five monetary recruitment incentives.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Table 5: Monetary Recruitment Incentives for BOP Health Care Personnel
Incentive
Description
Service
Agreement
Monetary Bonus
Lump-sum payment, up to 25 percent of pay, to a newly appointed
employee in a position that is difficult to fill with a high-quality
candidate.
24 months
Relocation
Lump-sum payment, up to 25 percent of pay, to current BOP
employees who relocate to a designated hard-to-fill location.
24 months
Student Loan
Repayment
Up to $10,000 per calendar year for up to six years, not to exceed a
maximum amount of $60,000.
36 months
Starting Pay
Appointed at a salary rate above the minimum step of a candidate’s
qualifying grade, based on superior qualifications for non-attorney
positions.
None
Title 38
Special pay authority for all BOP physicians, dentists, and
psychiatrists.
None
Source: BOP, Program Statement 3530.02: Compensation.
Our analysis showed that from January 1, 2019, through December 31, 2021, BOP paid $8.45
million in recruitment bonuses, relocation incentives, and student loan repayments. Table 6
summarizes the number of employees and amounts paid for each of these three types of incentives
by calendar year.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Table 6: Number of Employees and Dollar Amounts of BOP Recruitment Incentive Payments for
Calendar Years 2019 Through 2021
Recruitment Bonus
Relocation Incentives
Student Loan Repayment
Calendar
Year
Number of
Employees
Amount
 Paid
Number of
Employees
Amount
 Paid
Number of
Employees
Amount
 Paid
2019
89
$1,556,658
6
$74,432
148
$1,378,111
2020
95
$1,901,926
5
$98,412
126
$1,207,059
2021
39
$707,014
5
$71,432
158
$1,463,735
Total
223
$4,165,599a
16
$244,276
278b
$4,048,905
Source: DOJ OIG analysis of BOP data.
a.	 Total does not equal the actual sum because of rounding.
b.	 Employees may receive student loan incentive payments over several years and increments. As a result, the total amount
depicted in the Table represents a unique count of any employee receiving student loan repayment from 2019 to 2021, as
opposed to a cumulative total of the employee count for each year.
Additionally, the BOP used its title 38 personnel authorities to hire 34 medical officers and
20 dental officers between January 1, 2019, and December 31, 2021. A regional HSA stated
that expanding title 38 authorities from psychiatrists to physicians and dentists in 2019 was
a “significant improvement” that helped the BOP to compete with the private sector and other
governmental agencies. Finally, BOP officials cited a pay-setting authority known as above the
minimum rate (AMRs) that helped hire health care personnel. Based on our analysis of AMR
incentives for health care personnel, we found that the BOP used this authority 540 times to attract
candidates from outside government service between January 1, 2019, and December 31, 2021.
Further, 385 of 540 (71 percent) of all AMR incentives applied to health care personnel were given
to nurses.
In addition to the above monetary incentives, BOP officials cited both direct hire authority and the
negotiation of annual leave credits as helpful, non-monetary recruitment tools. Through authority
granted by the OPM, the BOP can leverage government-wide direct hire authorities for five types of
health services positions at all its institutions.32 However, a senior BOP human resources official
stated that the BOP did not have the human resources staff with the necessary skills to leverage
this authority enterprise-wide. Our analysis revealed that from 2019 to 2021, the BOP only used
direct hire authorities for health services personnel at three of its institutions, all medical centers,
for a total of 71 health care direct hires.

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Retention Incentives
BOP officials reported that one of the main factors contributing to turnover in health services
personnel was BOP’s low compensation compared to other federal agencies and the private sector.
Our analysis of exit surveys for health services staff from FY 2019 through FY 2022 found that pay
was the most frequently cited factor for why employees were leaving. To improve health services
retention, BOP spent $19.39 million in retention incentives to over 1,100 health care employees
from January 1, 2019, through December 31, 2021. Table 7 summarizes the number of employees
and amounts paid for retention incentives, by calendar year.
Table 7: Number of Employees and Dollar Amounts of BOP Retention Incentive Payments for
Calendar Years 2019 Through 2021
Calendar Year
Number of Employees
Amount Paid
2019
469
$6,311,308
2020
461
$6,918,848
2021
420
$6,162,232
Total
1,107a
$19,392,388
Source: DOJ OIG analysis of BOP data.
a.	 Employees may receive retention incentives for multiple years. As a result, the columns showing the total number of employees
receiving retention incentives by year and the cumulative total number of employees who received retention incentive payments
over the 3 years do not total.
In addition to monetary incentives, BOP officials reported the following efforts to retain existing
health care personnel.
•	 Approving compressed work schedules
•	 Awarding time-off incentives
•	 Granting permission for outside employment
•	 Emphasizing the ability to retire with law enforcement benefits after 20 years of service at age
50

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VHA
HHS
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Justice
DOJ
Efforts to Minimize Burnout
According to both BOP officials we interviewed and exit surveys from separated health services
employees, numerous staff left the BOP because of the increased workload resulting from the
pandemic and lower staffing levels. One regional HSA stated that BOP’s health services personnel
worked very hard during the pandemic and experienced burnout, which in turn caused a lot of
turnover.
To reduce health care personnel burnout, BOP officials stated that they encouraged personnel to
access the BOP’s Employee Assistance Program and encouraged management to monitor and
support staff well-being. During the pandemic, BOP institutions also activated Correctional Support
Teams, previously called Crisis Support Teams, which provided peer support to staff in response to
critical incidents. However, the Correctional Support Team model, which entailed peer support staff
walking throughout facilities and talking to staff members, were limited because of the pandemic
modifications, such as social distancing and staff movement restrictions.

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DOD
DOJ
VHA
HHS
U.S. Department of
Veterans Affairs (VA)
The Veterans Health Administration (VHA) runs the largest integrated health care network in the
United States, providing services through 140 facilities encompassing over 1,200 sites of care,
including VA Medical Centers and outpatient settings. More than 371,000 health care professionals
provide comprehensive health services, including telehealth.33 As of September 2022, over 9
million veterans were enrolled. In addition to caring for veterans, VHA also serves qualifying
family members, dependents, and survivors of veterans; and eligible active military and Reserve
Component members.
COVID-19’s Impact to the VHA
The COVID-19 pandemic altered the delivery of health care in the VHA in several ways. For example,
VHA facilities began shifting care from in-person to telehealth to limit face-to-face interaction. The
demand for inpatient care also increased as COVID-19 hospitalizations grew, whereas the demand
for elective and outpatient care decreased. In addition to facing these alterations in the delivery
of health care during the pandemic, VA serves as the nation’s support system during times of
emergencies.34
Scope of VA OIG Review
This review summarizes information on shortages at 139 of 140 VHA facilities for FYs 2020-
2022, including data gathered through an annual VA OIG survey. The Manila facility was excluded
because its staff were foreign nationals employed by the State Department. For the survey, VHA-
identified facility points of contact reported severe occupational shortages among both clinical
and nonclinical occupations employed by VHA. Severe occupational shortages should not be
confused with vacancies. A severe occupational shortage refers to particular occupations that are
difficult to fill, and a shortage exists when criteria set forth in 5 C.F.R. § 337.204, Severe Shortage
of Candidates, are applied. Vacancy refers to an unoccupied position and is distinct from the
designation of a severe occupational shortage. For example, a facility could identify an occupation
as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.
(See Appendix C: VA OIG methodology and Appendix E: Shortages Reported by at least 20 percent
of VHA Facilities)

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DOJ
HHS
VHA
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  Veterans Health Administration
Health Care Personnel Shortages Before and During
the Pandemic
In response to VA OIG concerns related to access to VHA care, scheduling practices, and excessive
wait times at the Phoenix Health Care System, Congress passed the Veterans Access, Choice, and
Accountability Act (VACAA) of 2014.35 VACAA and the subsequent VA Choice and Quality Employment
Act (VCQEA) of 2017 required the VA OIG to provide annual determinations of VHA occupations with
the largest shortages.36 VACAA and VCQEA also established authority for the Secretary of Veterans
Affairs to directly recruit and appoint qualified personnel to occupations determined to have staffing
shortages by the VA OIG. For each of the time periods discussed in this review, the VA OIG found
widespread shortages across VHA facilities.37
Severe Occupational Shortages from FY 2020 Through FY 2022
All 139 VHA facilities reported at least one severe occupational shortage in FY 2022, a departure
from the FYs 2020–2021 VA OIG reports in which several facilities reported no severe occupational
shortages.38 The total number of severe occupational shortages reported by facilities in FY 2022
survey responses increased comparatively as seen in Table 1. For the first time since reporting to
the facility level, there was a net increase in severe occupational shortages suggesting it was more
difficult to fill positions in VHA. Additionally, 22 occupations were identified as a severe occupational
shortage by at least 20 percent of facilities in FY 2022. This was an increase of occupations from
19 in FY 2021 and 17 in FY 2020. See Appendix E for shortages reported by at least 20 percent of
facilities from FYs 2020-2022.
Table 1: Changes in Total VHA Facility-Designated Severe Occupational Shortages from the Prior
Fiscal Year
Fiscal Year
Number of Severe
Occupational Shortages
Net Change from Prior Fiscal Year
Number
Percent
2020
2,430
-255
-9.5
2021
2,152
-278
-11.4
2022
2,622
 470
21.8
Source: VA OIG analysis of VHA facilities’ responses to the VA OIG’s FYs 2019 through 2022 staffing surveys.

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DOJ
HHS
VHA
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  Veterans Health Administration
Most Frequently Reported Severe Occupational Shortages
Medical Officer and Nurse Severe Occupational Shortages
Medical officer and nurse occupational series were analyzed separately from the other occupations,
because VHA uses assignment codes to designate specialties within the two OPM occupational
series. VA OIG derived medical officer and nurse severe occupational shortages for the series if the
facility indicated either the OPM occupational series or any of its related VHA assignment codes as
shortages.
In FY 2022, 87 percent of facilities reported the medical officer OPM occupational series or a
related VHA assignment code as a severe occupational shortage. This shortage was a decrease
from FY 2021, when 90 percent of facilities listed a shortage for the occupation.  In FY 2020, 87
percent of facilities listed the medical officer OPM occupational series or a related VHA assignment
code as a severe occupational shortage.
In FY 2022, 91 percent of facilities reported the nurse OPM occupational series or a related VHA
assignment code as a severe occupational shortage. This was up from FY 2021, when 73 percent
of facilities listed the nurse occupation as a shortage. In FY 2020, the nurse OPM occupational
series or a related VHA assignment code was reported as a severe occupational shortage by 72
percent of facilities.
Exhibit 1: Percent of VHA Facilities Reporting Shortages for Medical Officer and Nurse
Occupations, FYs 2020-2022
Medical officer
Nurse
FY 2022
FY 2021
FY 2020
87%
87%
90%
FY 2022
FY 2021
FY 2020
91%
72%
73%
Source: VA OIG analysis of VHA facilities’ responses to the VA OIG’s FYs 2020, 2021, and 2022 staffing surveys.
VA OIG also assessed severe occupational shortages at the assignment code level to assess severe
shortages for the medical officer and nurse series in more detail as compared to other occupations.

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  Veterans Health Administration
Shortages in Clinical Occupations
For all three FYs in the review period, the same five occupations were reported as the top five
clinical shortages. For FY 2022, the practical nurse clinical occupation was the most frequently
reported clinical occupation, with 62 percent of VHA facilities reporting it as a shortage. For the FY
2021 annual determination of shortages, the VA OIG found that 50 percent of facilities designated
the psychiatry specialty assignment code in the medical officer series as a severe occupational
shortage, making it the most frequently cited clinical occupation shortage. For the FY 2020 annual
determination of shortages, the VA OIG found that 60 percent of facilities designated the psychiatry
specialty assignment code in the medical officer series as a severe occupational shortage, making
it the most frequently cited clinical occupation shortage. See Exhibit 2 below.
Exhibit 2: Percent of Facilities Reporting Top Five Clinical Occupational Shortages, FYs 2020-2022
Psychiatrya
Practical Nurse
Psychology
Primary Carea
Medical
 Technologist
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
51%
50%
60%
62%
37%
35%
53%
43%
34%
43%
41%
37%
47%
36%
32%
Source: VA OIG analysis of VHA facilities’ responses to the VA OIG’s FYs 2020, 2021, and 2022 staffing surveys.
a.	 Assignment codes within the Medical Officer occupational series.

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  Veterans Health Administration
Shortages in Nonclinical Occupations
As with the top five clinical occupations, the same five occupations were listed as the top nonclinical
shortages for all three FYs in the review period. In FY 2022, for the first time since the VA OIG began
reporting both the top five clinical and nonclinical occupational shortages in 2018, nonclinical
occupations represented the top two severe occupational shortages. In FY 2021, medical support
assistance was the most frequently reported nonclinical shortage occupation, which 45 percent of
facilities designated as a severe occupational shortage. Custodial worker was the most frequently
reported nonclinical shortage occupation in FY 2020, with 47 percent of facilities designated as a
severe occupational shortage. See Exhibit 3 below.
Exhibit 3: Percent of VHA Facilities Reporting Top Five Nonclinical Occupational Shortages, FYs
2020-2022
Custodial
 Worker
Medical Support
 Assistance
Police
General
 Engineering
Food Service
 Worker
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
FY 2022
FY 2021
FY 2020
69%
42%
47%
63%
45%
26%
45%
43%
45%
39%
32%
35%
43%
29%
27%
Source: VA OIG analysis of VHA facilities’ responses to the VA OIG’s FYs 2020, 2021, and 2022 staffing surveys.

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  Veterans Health Administration
Contributing Factors that Led to Shortages of Health
Care Personnel
As part of the FY 2020 occupational shortage survey, the VA OIG asked VHA facilities to provide a
reason for each designated shortage. The VA OIG identified themes among free text responses to
summarize the most common reasons for shortages. The most frequently cited reasons for severe
occupational shortages among the top five clinical and top five nonclinical occupations were: (1)
lack of qualified applicants, (2) noncompetitive compensation, (3) staff turnover, (4) recruitment
challenges, and (5) geographical recruitment challenges.39 The lack of qualified applicants theme
was used to identify those responses that referred to a limited number of applicants, a lack of
applicants, as well as a limited number of qualified applicants. The noncompetitive compensation
theme was used to identify responses that referred to noncompetitive salaries, benefits, and
incentives. The staff turnover theme was used to identify responses that mentioned turnover of
staff and included references to retention, retirement, and promotion. The recruitment challenges
theme was used to identify responses that referred to recruitment difficulties, hard to fill positions,
and extended time to fill positions. The geographic recruitment challenges theme was used to
identify responses that referred to recruitment difficulties driven by a facility’s location.
Exhibit 4: Percentage of Top Reasons Reported by VHA Facilities for Shortages in Top Five Clinical
and Top Five Nonclinical Shortage Occupations in FY 202040
Lack of Qualified Applicants
Noncompetitive
 Compensation
Staff Turnover
Recruitment Challenges
Geographical
 Recruitment Challenges
37%
34%
32%
26%
23%
Source: OIG analysis of VHA facilities’ responses to the FY 2020 Staffing Determination and Staffing Model survey.

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  Veterans Health Administration
Impacts of Shortages of Health Care Personnel
Examples of impacts identified by VHA officials are listed below. While these examples are attributed
to staffing shortages, they may also be associated with additional factors related to changes in the
delivery of health care as part of the response to COVID-19.
Health Care Personnel Impacts
For FY 2020, human resources management was reported as a shortage by 22 percent of VHA
facilities. While the human resources occupational series were not reported as severe occupational
shortages by more than 20 percent of facilities in FYs 2021 and 2022, those occupations were
consolidated from the facility to the Veterans Integrated Service Network (VISN) level as part of
VHA’s HR Modernization effort.41 When asked about impacts of a hiring surge to address shortages
related to COVID-19, VISN directors reported the unanticipated workload compounded existing
shortages and burnout among human resources personnel.
VHA’s Reduce Employee Burnout and Optimizing Organizational Thriving (REBOOT) Task Force,
established in Fall 2021, found that staffing challenges were reported by employees as the top
contributor to burnout, followed by COVID-19 and pay issues.
Patient Impacts
In each of the VA OIG’s annual shortages reports during the time periods for this review, the
VHA identified severe occupational shortages in medical officer and nurse occupations. These
two occupations are key to the delivery of health care and have been the most commonly cited
shortages since 2014.42 A 2022 report by ECRI summarized research identifying health care
personnel shortages as the top patient safety concern, showing such shortages caused for longer
waits for care, including in life-threatening situations.43 Similarly, CDC guidance used by VHA for
mitigating personnel shortages during the COVID-19 pandemic indicates that appropriate staffing is
essential for safe patient care.44
Psychiatry and psychology were both in the top five clinical occupations reported by VHA facilities
in VA OIG staffing shortage reports for FYs 2020 through 2022. These two occupations are key to
the delivery of mental health services for patients, including in VHA’s Primary Care Mental Health
Integration (PCMHI) model of care.  A December 2022 GAO report reviewed annual VHA surveys
and found that 43 percent of facilities reported staffing as the most significant challenge to
implementing PCMHI programs in 2022.45 The GAO concluded that a “full complement of mental
health professionals is imperative for VA to be able to meet the rapid growth in demand for VA
Mental Health services” and recommended a comprehensive evaluation and implementation of
strategies to mitigate PCMHI staffing challenges.

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  Veterans Health Administration
Nearly twice as many facilities reported medical support assistance as a severe occupational
personnel shortage in FY 2021 than in FY 2020 (62 versus 36, respectively). More facilities may
have reported medical support assistance as a severe occupational shortage in FY 2021 as a
result of the pandemic. During the first year of the pandemic, VHA doubled the number of patients
utilizing telehealth and other virtual modalities, compared to the prior year, relying heavily on
medical support assistance to cancel, reschedule, and facilitate virtual appointments between
patients and providers.46 VHA providers reported that availability of medical support assistance
led to more success in completing telehealth appointments.47 Other VA OIG work identified that
about 7.3 million VHA appointments were canceled early in the pandemic from March 15 through
May 1, 2020.48 The VA OIG concluded that schedulers would likely be in demand as VHA worked to
reschedule the canceled appointments.
Operational Impacts
As part of the pandemic response, VHA also used the medical support assistance occupation
in outpatient administrative positions for screening protocols, adding additional impact of any
shortages in the occupation. Custodial worker was the most cited nonclinical severe occupational
shortage in FYs 2020 and 2022, and among the top five most frequently reported shortages overall
for FYs 2020 through 2022.  In FY 2020, VHA’s COVID-19 Response Plan required both routine
cleaning, as well as additional cleaning and disinfection, if someone presented with COVID-19
symptoms or is exposed, making an already vital occupation more important during a pandemic.49
Efforts to Recruit New Staff, Retain Existing Staff, and
Minimize Burnout During the Pandemic
Widespread occupational shortages across VHA predate the pandemic, and so do efforts and
approaches aimed at reducing those shortages. Such efforts include the use of direct hire authority
available to VA with OPM approval, as well as VA-specific direct hire authority based in part on VA
OIG annual shortage determinations.50 VHA also gained resources and flexibilities created in direct
response to the pandemic. Additionally, VHA received legislative relief and made use of other
approaches to reduce shortages not necessarily tied to the pandemic. In October 2022, the Under
Secretary for Health announced hiring faster and more competitively as one of VHA’s six priorities.
The examples provided below should not be considered an all-inclusive list of the VHA efforts to
mitigate shortages of health care personnel.

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  Veterans Health Administration
Recruitment and Retention Incentives
Direct Hire Authority
VA has authority to make noncompetitive appointments based on a determination by OPM that a
severe occupational shortage of highly qualified candidates exists for applicable occupations.51 The
VA Secretary also has the authority to directly recruit and appoint qualified individuals to applicable
occupations based upon a determination of occupations with the largest shortages by the VA OIG.52
After the Worldwide Health Organization declared COVID-19 a worldwide pandemic, VA sought and
obtained direct hire authority for several occupations from OPM beginning on March 23, 2020. OPM
subsequently extended the direct hire authority for occupations covered by those requests through
the end of the pandemic.
Onboarding Processes
To expedite hiring of new staff during the pandemic, VHA implemented changes and waivers in the
onboarding process. These changes included delaying fingerprinting, physical exams, drug testing,
and portions of the credentialing processes until after employees began work. VHA also began
starting employment for new employees throughout the pay period, rather than waiting for the next
two-week pay period to begin.
Pandemic Staffing Strategies
VHA’s COVID-19 Operational Plan uses CDC guidance providing for conventional, contingency, and
crisis capacity staffing strategies. These strategies are implemented on the authority of facility
leadership “in a targeted fashion,” such as for a single clinic critical to supporting the facility.53
Contingency staffing includes targeted implementation of recruitment and retention flexibilities or
strategies, along with the activation of Clinical Deployment Teams (CDT).54 Crisis staffing includes
implementing all recruitment and retention flexibilities or strategies, contracting for additional staff,
activating CDT, and activating the Disaster Emergency Management Personnel System (DEMPS).55
Additionally, VHA responded to changes in workload and personnel demands associated with
COVID-19 in various ways such as training outpatient doctors and elective procedure nurses in
competencies necessary to deliver care in inpatient settings.
CARES Act
Through the Coronavirus Aid, Relief, and Economic Security Act, Congress appropriated money
for VA to increase staffing levels.56 In an April 2020 press release, the VA’s Office of Public and
Intergovernmental Affairs noted that VA was moving “aggressively” to hire staff who could provide
care for the rising number of patients as a result of the pandemic.
VA Nurse and Physician Assistant RAISE Act of 2022
As part of the Consolidated Appropriations Act, 2022, the Department of Veterans Affairs Nurse
and Physician Assistant Retention and Income Security Enhancement Act, also known as the VA

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  Veterans Health Administration
Nurse and Physician Assistant RAISE Act. The Act increased pay caps for certain Registered Nurses
(RN) by $27,400 and Advanced Practice Registered Nurses (APRN) and Physician Assistants (PA) by
$50,000.57
Honoring Our PACT Act of 2022
The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive
Toxics Act of 2022, or the Honoring our PACT Act of 2022, contained various provisions for the
improvement of the VA workforce. Some of these enhancements include:
•	 buying out non-VA service contracts of certain health care professionals in rural settings;
•	 increasing pay caps and waiving annual pay limitations for certain VHA employees;
•	 removing preference eligible requirements for housekeeping aid positions; and
•	 providing additional authorities to provide bonuses, awards, incentives, and student loan
repayments.58
Loan Forgiveness and Employee Educational Resources
VA provides several of its own loan forgiveness and reduction programs in addition to the Public
Service Loan Forgiveness Program, as well as scholarship opportunities to recruit and retain
employees.
Table 2. VA Loan Forgiveness and Employee Educational Resources
•
•
Education Debt Reduction Program
Provides student loan reduction to employees who provide
direct patient care.
Student Loan Repayment Program
Provides loan repayments to highly qualified candidates who
enter into a service obligation.
Employee Incentive Scholarship
Program
Provides scholarships for permanent employees who agree to a
service obligation to obtain education that would qualify them
for certain occupations.
National Nursing Education Initiative
Funds education for nurses who agree to a service obligation to
obtain a bachelor’s or advanced degree in nursing.
VA National Education for Employees
Program
Covers education expenses for permanent employees who
agree to a service obligation to obtain education that would
qualify them for certain occupations.
Source: VA OIG Review of VA Loan Forgiveness and Employee Educational Resources

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Addressing Burnout
The VHA Reduce Employee Burnout and Optimizing Organizational Thriving (REBOOT) Task Force
was established in fall of 2021. Its goal is to implement actions in response to issues identified
by VHA employees, including “staffing concerns, impacts of COVID-19, pay, recruitment, time
off, scheduling flexibilities, the ability to work part time and other challenges.”  The initiative is
structured into workgroups to address drivers of burnout including unmanageable workload,
perceived lack of fairness, lack of job control, low recognition or organizational support,
interpersonal conflict, and mismatched values.59 To address unmanageable workload, one of
REBOOT’s main objectives is to maximize use of hiring policies and flexibilities including incentives
for recruitment, retention, and relocation of personnel for shortage occupations.

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HHS
U.S. Department of
Health and Human
Services (HHS)
HHS’s CMS administers the Medicare and Medicaid programs.60 The Medicare program provides
health care coverage to people aged 65 and older, people with disabilities, and people with end-
stage renal disease (permanent kidney failure). Medicare covers short-term skilled nursing and
rehabilitative care for Medicare enrollees in a nursing home after a hospital stay. The Medicaid
program provides health care coverage to individuals who have limited income and resources,
regardless of their age. Medicaid covers skilled, rehabilitation, and long-term care services in a
nursing home when other payment options are not available and when the individual is eligible for
Medicaid.
Nursing Homes
Nursing homes provide services to individuals whose capacity for self-care is limited because of a
chronic illness; injury; physical, cognitive, or mental disability; or other health-related conditions.
Services are provided to help individuals improve or maintain an optimal level of physical
functioning and quality of life. Services can include skilled rehabilitation, including physical,
occupational, and speech therapy, and assistance with daily tasks, such as dressing, bathing,
eating, medication management, and health maintenance tasks. As of July 1, 2022, there were
15,178 Medicare– and Medicaid–certified nursing homes nationwide, with 1.6 million beds and 1.2
million residents.61
COVID-19’s Impact on Nursing Homes
The pandemic has had a significant impact on nursing homes. As of the week ended September 11,
2022, nursing home residents had accounted for more than 1.2 million confirmed COVID-19 cases
and more than 156,000 COVID-19-related deaths, and nursing home staff had accounted for more
than 1.3 million confirmed cases and more than 2,600 deaths.62
The Assistant Secretary for Planning and Evaluation (ASPE) for HHS wrote in an October 2020
report that the pandemic imposed high demands on nursing homes because they had to respond
quickly to suppress the threat and transmission of COVID-19, make rapid changes in how they
delivered care to residents, and implement new guidelines and measures to safeguard residents
and nursing home staff. According to the ASPE, during the pandemic, nursing homes grappled with
how to retain adequate staffing while rapidly making operational changes to ensure the safety of

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HHS
residents and staff. At the same time, according to the ASPE, staff have balanced concerns about
their own safety, the well-being of the residents under their care, and their own financial stability.63
Nursing Home Staff
Nursing home staff include staff who provide direct care to nursing home residents, as well as staff
who manage and maintain the nursing home. These staff can be employees of the nursing home or
hired under contract or through a staffing agency. According to the staffing categories that nursing
homes use to report staffing shortage data to the NHSN, nursing home staff consist of nurses,
clinical staff (such as physicians), aides, and other staff (such as social workers and housekeeping
staff).
Nurses
Nurses include RNs and licensed nurses. RNs are responsible for overseeing the care provided
to nursing home residents by other staff, such as licensed nurses and aides. An RN’s duties can
include initiating resident treatment plans, ensuring that residents are receiving proper care,
preparing intravenous lines, administering medications through injections, and interacting with
residents’ families. Licensed nurses also provide direct care and are typically responsible for
residents’ day-to-day care and personal hygiene. A licensed nurse’s duties can include taking
resident vital signs (such as blood pressure and body temperature), administering medications,
inserting catheters, and recording any changes in residents’ health or vital signs.
Clinical Staff
Clinical staff include physicians, physician assistants, and advanced practice RNs. A physician is
responsible for examining residents; taking resident medical histories; prescribing medications; and
ordering, performing, and interpreting diagnostic tests. A physician assistant typically provides the
same services as a physician but performs these services under the supervision of a physician. An
advanced practice RN can provide direct care to residents and often serves in leadership roles and
may educate and advise other nursing staff.
Aides
Aides include certified nurse assistants (CNAs), nurse aides, medication aides, and medication
technicians. Aides provide or assist residents with basic care and support under the direction of
onsite licensed nursing staff. An aide’s duties can include feeding, bathing, dressing, and grooming
residents; assisting residents with walking; and performing any other tasks that an RN or a licensed
nurse assigns to the aide. Aides in some states, in accordance with state law, can also administer
medications to residents.

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Other Staff
Other staff include nursing home staff who are not included in the prior three categories, such as
respiratory therapists, occupational and physical therapists, social workers, feeding assistants, and
staff responsible for a nursing home’s administration, housekeeping, and maintenance.
Federal Reporting Requirements Related to Nursing Home Staffing
In response to the pandemic, CMS required nursing homes to report whether they had a staffing
shortage for each type of staff position to CDC’s NHSN on a weekly basis from May 11, 2020,
through December 31, 2024.64
Federal regulations require nursing homes to report staffing information in CMS’s PBJ system
quarterly, such as the number of staff who provide direct care and services to residents, including
information for contract and agency staff. The reported information is based on payroll and other
verifiable and auditable data and must include the category of work for each person who provides
direct care and services to residents, and information on hours of care provided by each category
of staff per resident, per day.65 The data must also include the number of hours that each staff
member was paid to work each day within the quarter.66
Scope of HHS OIG Review
To understand nursing homes’ staffing experiences before and during the pandemic, the HHS
OIG interviewed officials from 50 nonstatistically selected nursing homes in 44 states. To provide
information on nursing homes’ staffing experiences during the pandemic, the HHS OIG analyzed
staffing shortage data from the NHSN that were available from the week ended May 24, 2020,
through the week ended September 11, 2022. Although CMS initially required nursing homes to
report staffing shortage data beginning the week ended May 17, 2020, CMS allowed nursing homes
to submit their first set of staffing shortage data beginning with the week ended May 24, 2020. The
HHS OIG also analyzed nursing home staffing data from the PBJ that were available for the quarters
ended June 30, 2019, through June 30, 2022, which encompassed periods before and during the
pandemic. For HHS OIG’s methodology, see Appendix D: HHS.

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HHS
Nursing Home Staffing Shortages Before and During
the Pandemic
For the 50 nonstatistically selected nursing homes, officials from 35 nursing homes stated that
their nursing homes had a staffing shortage at some point before the pandemic. In addition,
officials from all 50 nursing homes stated that their nursing homes had a staffing shortage at some
point during the pandemic.
Nationwide staffing shortage data for the weeks ended May 24, 2020, through September 11,
2022, showed that 12,500 nursing homes, or 80 percent of all nursing homes, reported a staffing
shortage at some point during the pandemic. Overall, there was an increase in the number of
nursing homes that reported a shortage for the weeks ended May 24, 2020 (3,157 nursing homes)
through September 11, 2022 (3,503 nursing homes). The number of nursing homes that reported
a shortage ranged from a low of 2,798 for the week ended March 21, 2021, to a high of 5,027 for
the week ended January 23, 2022. Exhibit 1 shows the number of nursing homes that reported a
staffing shortage anytime during the weeks ended May 24, 2020, through September 11, 2022.
Exhibit 1: Number of Nursing Homes Nationwide That Reported a Staffing Shortage During the
Pandemic
Number of Nursing Homes
(Week Ended Date)
3,157
(5/24/2020)
2,798
(3/21/2021)
5,027
(1/23/2022)
3,503
(9/11/2022)
Source: HHS OIG analysis of nursing home staffing shortage data reported to the NHSN.

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HHS
Staffing Shortage Data by State
Nationwide staffing shortage data for the weeks ended May 24, 2020, through September 11,
2022, showed that the percentage of nursing homes that reported staffing shortages during the
pandemic varied by state. Across all states, the average percentage of nursing homes that reported
a shortage during the pandemic increased from 22 percent to 28 percent. For the week ended May
24, 2020, the percentage of nursing homes in each state that reported a shortage ranged from 3
percent to 44 percent, including 8 states in which at least 30 percent of nursing homes reported
a shortage. For the week ended September 11, 2022, the percentage of nursing homes in each
state that reported a shortage ranged from 1 percent to 60 percent, including 11 states in which
at least 40 percent of nursing homes reported a shortage. Exhibit 2 shows maps that indicate the
percentage of nursing homes in each state that reported a staffing shortage for the weeks ended
May 24, 2020, and September 11, 2022.
Exhibit 2: Percentage of Nursing Homes in Each State That Reported a Staffing Shortage for the
Weeks Ended May 24, 2020, and September 11, 2022
Week Ended May 24, 2020
Week Ended September 11, 2022
1-10%
11-20%
21-30%
31-40%
41-50%
51-60%
Source: HHS OIG analysis of nursing home staffing shortage data reported to the NHSN.

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Positions Most Affected by Nursing Home Staffing Shortages
Aides and nurses were the two positions most affected by staffing shortages, both before and
during the pandemic. Exhibit 3 shows, by position, how many of the nonstatistically selected 50
nursing homes reported staffing shortages before and during the pandemic.
Exhibit 3: Number of the 50 Nonstatistically Selected Nursing Homes That Reported Staffing
Shortages Before and During the Pandemic, by Position
Before the Pandemic
During the Pandemic
33
50
29
47
9
38
Aides
Nurses
Other Staff
Source: HHS OIG interviews of officials from 50 nonstatistically selected nursing homes.
Note: Nursing home officials did not indicate whether they experienced a shortage of clinical staff before or during the pandemic.
Nationwide staffing shortage data for the weeks ended May 24, 2020, through September 11,
2022, showed that the number of nursing homes that reported shortages of aides and nurses
varied weekly and increased overall during the pandemic. For aides, the number of nursing homes
that reported a shortage was lowest at 2,410 during the week ended March 14, 2021 and highest
at 4,544 during the week ended January 23, 2022. For nurses, the number of nursing homes that
reported a shortage was lowest at 2,162 during the week of June 21, 2020 and highest at 4,301
during the week ended January 23, 2022. Exhibit 4 shows the number of nursing homes nationally
that reported a shortage of aides and nurses during the weeks ended May 24, 2020, through
September 11, 2022.

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HHS
Exhibit 4: Number of Nursing Homes Nationwide That Reported a Shortage of Aides and Nurses
2,594
(5/24/2020)
2,206
(5/24/2020)
4,301
(1/23/2022)
3,093
(9/11/2022)
2,162
(6/21/2020)
2,410
(3/14/2021)
4,544
(1/23/2022)
3,240
(9/11/2022)
Number of Nursing Homes (Week Ended Date)
Aides
Nurses
Source: HHS OIG analysis of nursing home staffing shortage data reported to the NHSN.
Number of Hours Worked by Nursing Home Staff
Staffing data from the PBJ for the quarters ended June 30, 2019, through June 30, 2022, showed
a decrease in the average daily number of hours worked by nursing home staff per nursing home.
Specifically, the average daily number of hours worked by aides decreased the most of any staff,
by 27 hours (13.8 percent). Additionally, the average daily number of hours worked by nurses
and other staff each decreased by 14 hours (10.9 percent and 18.4 percent, respectively). For
clinical staff, the decrease in the average daily number of hours worked per nursing home was
not material.67 Exhibit 5 shows the changes in the average daily number of hours worked by aides,
nurses, and other staff for the quarters ended June 30, 2019, through June 30, 2022.

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Exhibit 5: Average Daily Number of Hours Worked Per Nursing Home, by Position
Jun
Aug
Oct
Dec
Jun
Aug
Feb
Apr
Oct
Dec
Jun
Aug
Feb
Apr
Feb
Apr
Jun
Oct
Dec
2019
2020
2021
2022
Aides
Nurses
Other Staffa
196 Hours
129 Hours
76 Hours
169 Hours
115 Hours
62 Hours
Source: HHS OIG analysis of nursing home staffing data reported in the PBJ system.
a.	 Hours for other staff does not include hours that nursing homes’ housekeeping and maintenance staff worked.
Note: The decrease in the average daily number of hours that clinical staff worked was not material and is not presented in this
exhibit.
Contributing Factors That Led to Shortages of Nursing
Home Staff During the Pandemic
Officials from the 50 nonstatistically selected nursing homes identified various reasons for
shortages of nursing home staff during the pandemic. See Exhibit 6 for the top six reasons for
staffing shortages that these nursing homes identified and the number of nursing homes that
reported each reason.

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HHS
Exhibit 6: Top 6 Reasons for Staffing Shortages That 50 Nonstatistically Selected Nursing Homes
Identified
Increased Job Demands
Noncompetitive Pay
Fear of COVID-19
Increased COVID-19
 Protocols
Limited Labor Pool
Exposure to COVID-19
48
44
33
32
27
26
Source: HHS OIG interviews with officials from 50 nonstatistically selected nursing homes.
Increased Job Demands
Officials from 48 nursing homes stated that increased job demands contributed to staffing
shortages during the pandemic. Specifically, the officials commented that nursing homes are high-
stress and high-risk work environments, even with mitigation efforts in place. Staffing shortages
resulted in staff having less flexibility in their work schedules and having to work longer hours,
work extra shifts, and perform tasks that were not part of their regular duties. For example,
administrative staff, who were also licensed or certified as nurses or aides, assisted with resident
care or helped with laundry or janitorial duties. The increased demands led to staff burnout and
greater staffing shortages. The officials also commented that staff would rather work in jobs that
are less physically and mentally demanding for the same or similar pay rather than work extra hours
or carry excess workloads in a nursing home.
Noncompetitive Pay
Officials from 44 nursing homes commented that noncompetitive pay contributed to staffing
shortages during the pandemic. Officials from 40 of these 44 nursing homes stated that some of
their staff left their nursing home to take jobs with nurse staffing agencies, hospitals, other health
care providers, or other industries for higher pay. In addition, officials from 16 of the 44 nursing
homes commented that some of their staff chose to stop working after stimulus payments and
unemployment benefits were made available or were increased.

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DOJ
VHA
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  U.S. Department of Health and Human Services
HHS
Fear of COVID-19
Officials from 33 nursing homes stated that some staff quit their jobs or refused to work because of
their fear of COVID-19 infection. Specifically, the officials commented that some staff had underlying
health conditions and were afraid of getting sick themselves or spreading COVID-19 to family
members. Additionally, officials stated that other staff did not want to work directly with residents
who had contracted COVID-19 or work if cases of COVID-19 were reported in the building.
Increased COVID-19 Protocols
Officials from 32 nursing homes stated that the pandemic regulations and protocols contributed
to staffing shortages during the pandemic. Specifically, the officials commented that the increased
use of personal protective equipment, such as masks, regular COVID-19 testing, and COVID-19
vaccination requirements for health care workers caused some nursing home staff to leave their
jobs and seek employment at companies that did not have the same protocols and requirements.
Limited Labor Pool
Officials from 27 nursing homes stated that a limited labor pool had contributed to staffing
shortages. Officials from 23 of the 27 nursing homes commented that they had fewer applicants for
open positions and attributed the cause to fewer people wanting to work in nursing homes or having
a limited number of qualified applicants in their geographical area from which to recruit and hire.
Exposure to COVID-19
Officials from 26 nursing homes stated that staff exposure to COVID-19 led to staffing shortages.
Specifically, the officials commented that staff who contracted or were exposed to COVID-19 were
required to quarantine for a period of time, which left nursing homes short-staffed during those
periods. Additionally, officials from 4 of the 26 nursing homes stated that some staff were not able
to work because they had to take care of a family member who had contracted COVID-19. Also,
officials from 3 of the 26 nursing homes stated that some staff quit their nursing home jobs after
contracting COVID-19.

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DOD
DOJ
VHA
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Health and Human Services
HHS
Impacts of Shortages of Nursing Home Staff During
the Pandemic
Officials from the 50 nonstatistically selected nursing homes stated that staffing shortages had an
impact on remaining nursing home staff, nursing home operations, and nursing home residents
during the pandemic. Exhibit 7 shows the number of nursing homes from which officials stated they
had experienced these impacts.
Exhibit 7: Number of 50 Nonstatistically Selected Nursing Homes That Experienced the Impacts of
Staffing Shortages
Impacts on
 nursing home staff
Impacts on
nursing home operations
Impacts on
 nursing home residents
50
50
26
Source: HHS OIG interviews with officials from nonstatistically selected nursing homes.
Impacts on Nursing Home Staff
Officials from all 50 nursing homes reported impacts on nursing home staff. Nursing home officials
stated that the staffing shortages resulted in: (1) staff increasing their workloads, often working
longer shifts and covering the shifts of other staff, and (2) more staff calling out of work to avoid
increased workloads. The officials also stated that these conditions led to burnout and increased
levels of stress, anxiety, and depression. Officials further stated that, although nurse staffing
agencies played a crucial role in helping fill aide and nursing shortages, the use of agency staff
caused employee morale to decline among the nursing homes’ own staff because they worked
alongside agency staff who were paid more for the same work.
Impacts on Nursing Home Operations
Officials from all 50 nursing homes stated that staffing shortages had an impact on nursing
home operations, specifically on resident admissions and nursing home finances. The officials
commented that the shortages caused the nursing homes to reduce the overall number of new

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DOJ
VHA
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  U.S. Department of Health and Human Services
HHS
resident admissions, delay new admissions or transfers from hospitals for residents needing
rehabilitative care, and admit only residents who required less frequent or less intensive care.
Staffing shortages also caused nursing homes to incur higher costs for overtime pay and bonuses
for nursing home staff, as well as for agency staff whose wages were much higher than nursing
home staff. Officials stated that they also incurred costs for agency staff for “COVID pay” (additional
pay for working with COVID-19-positive residents), weekend hours, travel reimbursement, and
housing expenses.
Impacts on Nursing Home Residents
Officials from 26 nursing homes stated that staffing shortages had an impact on nursing home
residents. The officials commented that the shortages caused nursing homes to adjust the level
of care provided to residents. Adjustments included reducing or stopping restorative care, such as
bedside strength building and endurance activities that aides could provide without the expertise of
a licensed physical therapist, reducing physical rehabilitation services, and sending residents who
needed wound care to the hospital.
Nursing home officials stated that there was an overall decline in residents’ physical and mental
health because of staffing shortages and lower levels of care. The officials also stated that there
was an increase in the number of falls when residents attempted to stand on their own, an
increased number of pressure ulcers and infections, and longer wait times when residents called
for assistance.
Residents’ schedules and routines were also changed because of staffing shortages. According to
officials, having fewer staff resulted in residents receiving sponge baths in place of full showers or
baths, receiving necessary medications and getting put to bed at times different from their normal
schedules, and waiting longer for meals. In addition, officials stated that residents experienced
frustration and anxiety from having to interact with staff who were not familiar with their medical
histories or personalities.

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DOD
DOJ
VHA
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Health and Human Services
HHS
Efforts To Recruit New Staff, Retain Existing Staff, and
Minimize Staff Burnout During the Pandemic
Officials from the 50 nonstatistically selected nursing homes identified a variety of actions they
took to recruit and retain staff and minimize staff burnout during the pandemic. In addition, CMS
helped nursing homes respond to staffing shortages by waiving and modifying certain regulatory
requirements so that nursing homes could focus on resident care.
Recruitment Incentives
Nursing home officials commented that they took a variety of actions to recruit new staff. Officials
stated that they expanded their recruitment efforts by posting job openings on job recruiting
websites, in local newspapers, and on social media; attending job fairs; and working with local
colleges, local Chambers of Commerce, and health care associations to attract potential applicants
for positions. In addition to broadening their recruitment efforts, nursing homes provided incentives
to attract potential applicants. Table 1 shows examples of recruitment incentives offered by nursing
homes.
Table 1: Recruitment Incentives
•
•
Monetary Bonus
Offered sign-on and recruitment bonuses
Starting Pay
Offered increased starting wages
Continuing Education
Offered tuition assistance or reimbursement for education and
certification programs, such as nursing degrees, CNA certification,
and classes for those seeking the CNA certification
Training Programs
Implemented temporary nurse-aide training programs for staff who
had not met the CNA training and certification requirements
Flexible Schedules
Offered flexible hours
Restructured Compensation
Packages
Offered restructured compensation packages with higher pay and
fewer fringe benefits and the option to receive daily pay
Source: HHS OIG interviews with officials from nonstatistically selected nursing homes.

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DOJ
VHA
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  U.S. Department of Health and Human Services
HHS
Retention Incentives
Nursing home officials stated that they took various actions to retain existing staff. Table 2 shows
examples of retention incentives offered by nursing homes.
Table 2: Retention Incentives
•
•
Monetary Bonus
Offered retention bonuses and other bonuses to staff who worked with
residents who had COVID-19 or worked extra shifts
Increased Pay
Increased wages, including wages for those who worked night shifts
and weekends
Recognition
Showed employees more appreciation by providing free meals, gift
cards, and employee recognition events
Continuing Education
Offered tuition assistance or reimbursement for education and
certification programs, such as nursing degrees and CNA certification
Flexible Schedules
Offered flexible schedules when possible and reduced the number of
hours that staff were required to work to qualify for full-time benefits
Restructured Compensation
Packages
Offered restructured compensation packages with higher pay and fewer
fringe benefits, and the option to receive daily pay
Source: HHS OIG interviews with officials from nonstatistically selected nursing homes.
Efforts To Minimize Burnout
Nursing home officials stated that they took various actions to minimize burnout. Table 3 shows
examples of efforts to minimize burnout by nursing homes:

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DOJ
VHA
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  U.S. Department of Health and Human Services
HHS
Table 3: Efforts to Minimize Burnout
•
•
Contract Staff
Increased the use of nurse staffing agencies to fill shortages
Cross-Training
Employed an “all-hands-on-deck” approach, in which staff from various
departments in the nursing home stepped in to help departments with
staffing shortages, and cross-trained staff to perform other duties
Resident Admissions
Reduced the number of new resident admissions, delayed new
admissions, or admitted only residents who required less frequent or
less intensive care
Flexible Schedules
Offered flexible and compressed work schedules
Time-off
Tried to honor requests for time off
Staff Sharing Agreements
Made staff-sharing agreements with facilities under the same corporate
ownership or with contracted facilities that were short-staffed during
COVID-19 breakouts and when staffing shortages peaked
Mental Health
Offered psychological support onsite through health insurance or
through the local health department
Source: HHS OIG interviews with officials from nonstatistically selected nursing homes.
CMS’s Efforts to Help Nursing Homes Respond to Staffing Shortages
During the pandemic, CMS enacted a number of temporary emergency waivers to requirements
for nursing homes related to staff training, the performance of specific tasks, and administrative
reporting requirements, among others. These waivers provided nursing homes with extra flexibilities
as they responded to the challenges of the pandemic, and helped nursing homes respond to
staffing shortages.68 Table 4 shows examples of efforts implemented by CMS.

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DOJ
VHA
Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic
  U.S. Department of Health and Human Services
HHS
Table 4: Examples of CMS’s Efforts to Help Nursing Homes Respond to Staffing Shortages
•
•
Waived Nurse
Aide Employment
Requirements
CMS waived the requirement that a nursing home may not employ anyone for
longer than 4 months unless the individual has met the training and certification
requirements of 42 C.F.R § 483.35(d). The waiver allowed nursing homes
to employ an individual in a nurse aide role for longer than 4 months even if
the individual had not completed a state-approved Nurse Aide Training and
Competency Evaluation Program. The nurse aide could continue to work as long
as the nursing home ensured that the individual could demonstrate competency
in skills and techniques needed to care for residents.
Postponed Training
Deadlines
CMS modified the nurse aide training requirements that required nursing
assistants to receive at least 12 hours of in-service training annually by
postponing the deadline for completing the training requirement.
Allowed Physicians
to Delegate Tasks
CMS waived the requirement that prevents a physician from delegating certain
tasks that are otherwise required to be performed specifically by the physician.
The waiver allowed a physician to delegate certain tasks to a physician assistant,
nurse practitioner, or clinical nurse specialist, but it specified that the delegated
task must continue to be under the supervision of the physician.
Reduced Required
Training Hours
CMS reduced the training requirements for paid feeding assistants from a
minimum of 8 hours to a minimum of 1 hour.
Source: HHS OIG analysis of temporary COVID-19 emergency waivers enacted by CMS.

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APPENDIX A:
Department
of Defense
Section 1: Methodology
Scope. As of December 2022, the DOD had 45 military hospitals. The DOD OIG’s review focused
on shortages of health care personnel at 24 nonstatistically selected MTFs, or DOD hospitals. Our
review focuses on the MTF personnel experiences from March 1, 2019, through September 30,
2022.
The DOD OIG conducted this audit from July 2022 to May 2023.
Data Sources. The DOD OIG review used multiple sources of data, including the following.
•	 Interviews with officials from the 24 DOD medical treatment facilities that we selected for
review, the DHA, office of the Assistant Secretary of Defense for Health Affairs, and Service
medical commands.
•	 Manpower and recruiting data, where available, to corroborate interview statements. The
DHA provided personnel data for the civilians under its authority, direction, and control as of
January 2023 from the Defense Civilian Personnel Data system and the DHA Joint Table of
Distribution. The MTFs provided personnel data for military, civilians, and contractors under
their authority, direction, and control before the DHA transition from the Defense Medical
Human Resources System – internet; Activity Manpower Documents for Navy facilities
extracted by the MTFs from the Navy’s Total Force Manpower Management System; unit
manpower documents from the Air Force’s Manpower Programming & Execution System and
Medical Planning and Programming Tool; the MTF generated gain-loss rosters; recruitment
personnel actions; and staffing tables of distribution and allowances maintained by the MTFs
and extracted from each service’s databases, such as the Fourth Estate Manpower Tracking
System.
•	 Additional data, such as deployment trackers, staffing assist requests, civilian sector pay
surveys, and government and civilian sector job postings, to report reasons for shortages in
health care personnel.
•	 Additional data, such as access to care reports, premium hour reports, patient satisfactory
surveys, comprehensive systematic analyses, requests for personnel actions, and others, to
report examples of impacts of health care personnel shortages.

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  Appendix
•	 The DOD and the DHA guidance to identify mitigation strategies used by the DHA to recruit and
retain providers within the DOD.
Methodology. The DOD OIG selected a nonstatistical sample from the 26 MTFs that the DOD OIG
reported as a result of the MTF interviews that had “staffing and manpower shortages” as a serious
challenge in DOD OIG Report No. DODIG-2022-081, “Evaluation of Department of Defense Military
Medical Treatment Facility Challenges During the Coronavirus Disease–2019 (COVID-19) Pandemic
in Fiscal Year 2021,” April 5, 2022. To compare like facility types, we excluded three MTFs that
were not an inpatient hospital or medical center. We also added one additional MTF that identified
staffing and manpower as a serious future concern, for a total of 24 MTFs to determine if they were
still experiencing shortages of health care personnel. See Table 1 for the locations of the 24 MTFs
we nonstatistically sampled.
Table 1: Names and Locations of the 24 Nonstatistically Selected MTFs
•
•
673d Medical Group - Joint Base Elmendorf-Richardson
Elmendorf Air Force Base, Alaska
60th Medical Group - Travis Air Force Base
Travis Air Force Base, California
Naval Hospital Camp Pendleton
Camp Pendleton, California
Naval Medical Center San Diego
San Diego, California
Naval Hospital Twentynine Palms
Twentynine Palms, California
Naval Hospital Jacksonville
Jacksonville, Florida
Martin Army Community Hospital
Fort Benning, Georgia
Tripler Army Medical Center
Honolulu, Hawaii
Blanchfield Army Community Hospital
Fort Campbell, Kentucky
Walter Reed National Military Medical Center
Bethesda, Maryland
Womack Army Medical Center
Fort Bragg, North Carolina
Naval Medical Center Camp Lejeune
Camp Lejeune, North Carolina
88th Medical Group - Wright-Patterson Air Force Base
Wright-Patterson AFB, Ohio
William Beaumont Army Medical Center - Fort Bliss
Fort Bliss, Texas
Naval Medical Center Portsmouth
Portsmouth, Virginia
Madigan Army Medical Center
Tacoma, Washington
Naval Hospital Bremerton
Bremerton, Washington

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  Appendix
•
•
Army Community Hospital Weed-Irwin
Fort Irwin, California
Landstuhl Regional Medical Center
Landstuhl, Germany
Naval Hospital Rota
Rota, Spain
Naval Hospital Guam
Agana, Guam
Navy Medicine Readiness & Training Command Sigonella, Italy
Sigonella, Italy
48th Medical Group – Royal Air Force Lakenheath
RAF Lakenheath, United Kingdom
51st Medical Group - Osan Air Base
Osan Air Base, South Korea
Source: The DOD OIG.
We conducted virtual interviews with officials from the MTFs, the DHA, Office of the Assistant
Secretary of Defense for Health Affairs, and Service medical commands between August 11, 2022,
and March 17, 2023. We did not require specific personnel to participate in our interviews, but
rather requested that the MTF officials identify personnel they thought would offer the best insights
into staffing challenges, impacts, and mitigation strategies. Participants included individuals such
as the MTF commanders, public health emergency officers, hiring authorities, leaders for the MTF
administration and nursing, logisticians, among others. We asked open-ended questions about
the specialties or positions most affected by shortages of health care personnel; the causes of the
shortages; the impacts of the shortages; and any mitigating strategies used by the MTFs, the DHA,
or Services to recruit new personnel, retain existing personnel, and reduce burnout in health care
personnel.
We did not verify or confirm interview responses but requested, where available, that the DHA and
the MTF officials provide documentation to support their statements. If data provided by the MTFs
indicated shortages in a specific position, we included that position in our shortages analysis,
even if it was not mentioned by the MTF officials during our interviews. Following our interviews
and analysis of documentation, we counted the number of the MTFs that shared each health care
position shortage, cause, or impact.
Section 2: Limitations
The MTFs did not provide consistent, complete data to allow a comparison of authorized and
filled positions across our sample. However, the DHA provided personnel data for its civilians as
of January 2023. These personnel accounted for only a portion of health care personnel within
the MTFs, and did not include active duty Service members, contractors, or civilians working for
the Military Departments. Where available, we used the data that the MTF officials provided from
different systems and tracking mechanisms available to them to support statements or examples
they provided during interviews. Therefore, we may have underreported the number of the MTFs
encountering each position shortage, cause, or impact included in the report. We did not review

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  Appendix
incentives or strategies used to recruit or retain staff hired under contracts, as those incentives or
strategies would be developed by each contractor and not under the purview of the DOD.
At the time of our interviews, the MTFs transitioned or were in the process of transitioning their
civilian personnel to the DHA in line with section 702 of the FY 2017 National Defense Authorization
Act (NDAA) and sections 711 and 712 of the FY 2019 NDAA that required the Military Departments
transition the administration of all the MTFs to the DHA for the purpose of implementing an
integrated system of readiness and health.69 Additionally, some officials within the MTFs we
interviewed may not have been located at the MTF we interviewed them at in earlier periods of the
pandemic because Service members move regularly for training or job assignments, with most
rotations lasting 2 to 4 years. The information provided reflects the experiences of existing health
care personnel and their perceptions of former health care personnel experiences. Therefore,
officials may not have captured all reasons for shortages in health care personnel, the impacts of
the shortages, or efforts to recruit and retain health care personnel or minimize staff burnout.
Section 3: Standards
We conducted this review in accordance with generally accepted government auditing standards
issued by the Government Accountability Office. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings
and conclusions based on our audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit objectives. We relied on the
testimonies of the MTF personnel to form our overall findings and conclusions. We did not test or
rely on the validity of computer-processed data provided but, rather used the data to corroborate
the personnel shortages that were stated during the interviews.  We assessed internal controls and
compliance with laws and regulations necessary to satisfy the audit objective.

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APPENDIX B:
Department
of Justice
Section 1: Methodology
Scope. The review describes staffing levels of BOP civil service employees and commissioned
officers of the U.S. Public Health Service who worked in the health services units at BOP institutions
from January 2019 to July 2022. This review does not include the BOP’s psychology staff because
they are not part of BOP’s health services units. Additionally, this review does not include
information about contract health care providers who may provide specialized on-site care at BOP
institutions, cover institution vacancies on a short-term basis, or deliver care to BOP inmates at
community facilities not operated by the BOP.
We conducted fieldwork for this review from August 2022 through January 2023.
Data Sources. The DOJ OIG’s review included multiple data sources, including BOP policies,
guidance, and memorandums; BOP waivers; BOP documentation and written responses to OIG
requests; statutes related to recruitment and retention incentives; interviews with BOP central office
staff, BOP regional office staff, and BOP institution staff; the BOP’s human resources information
system for staffing data; BOP exit surveys; DOJ OIG Hotline complaints; BOP public website
population data; and a review of previously published OIG work.
Methodology. Our fieldwork included interviews, data collection, and analyses. Additionally, we
conducted document reviews of relevant policies, guidance, and workforce planning documents.
To understand health services staffing over time, we received and analyzed staffing data provided
by BOP’s Human Resources, Workforce Systems and Evaluation Section. Specifically, we obtained
individual records of health services staffing records of each authorized health services position,
including PHS positions, at every BOP institution for pay period 6 in 2019, 2020, 2021, and 2022.
We used the staffing data, in aggregate, to determine the distribution of health services position
types as well as to calculate fill rates enterprise-wide and for specific positions. We also reviewed
and analyzed hiring and separation data by pay period between January 2019 and June 2022.
To determine the extent to which augmentation was used during the pandemic, we analyzed
augmentation data by location and position type from January 2019 through August 2022, as
provided by the BOP. To determine the extent to which health services personnel worked overtime

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  Appendix
and the associated costs, we analyzed overtime transaction data from the National Finance Center.
For the overtime analysis, we considered health care occupational series codes (0600 series), as
well as the occupation series code for Social Workers (0185).
To examine the use of recruitment and retention incentives, we analyzed data provided by the BOP
on recruitment bonuses, relocation bonuses, retention incentives, and student loan repayments
given to health services staff between January 2019 and December 2021.
To help understand the causes and impacts of staffing shortages, and to learn about the BOP’s
efforts to recruit and retain staff, we interviewed regional and central office staff, including the
regional health services administrator or acting health services administrator, from each of the
BOP’s six regions; two regional human resources administrators; a central office human resources
official; and a national recruitment specialist. We also reviewed exit surveys from departing health
services personnel to understand the reasons for staff departure and suggestions for what could
have prevented them from leaving the BOP.
Finally, we summarized and incorporated information from oversight work previously published by
the DOJ OIG on the BOP’s response to the pandemic, including remote inspections of 16 facilities
housing BOP inmates, 2 surveys of BOP staff, 1 survey of inmates, and a COVID-19 Capstone report
that highlighted themes identified through the DOJ OIG’s COVID-19 oversight work and examined
COVID-19 themes that emerged following that work.
Section 2: Limitations
As discussed in the scope section of this appendix, this review does not include information about
contract health care providers who may provide specialized on-site care at BOP institutions, cover
institution vacancies on a short-term basis, or deliver care to BOP inmates at community facilities
not operated by the BOP. Additionally, the data did not cover staff availability during the period,
including whether staff were on sick leave or annual leave,
Section 3: Standards
We conducted this evaluation in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.

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APPENDIX C:
Department of
Veterans Affairs
Section 1: Methodology
Scope. The VA Choice and Quality Employment Act (VCQEA) of 2017 requires the VA OIG to report an
annual determination of VHA occupations that have the largest shortages at each medical facility.70
As part of this determination, we administer and analyze an annual survey of all VHA facilities.
The survey identifies severe occupational shortages across 139 VHA facilities.71 We also reviewed
VA and VHA directives, policies, memorandums, and documentation; and researched staffing
flexibilities granted by the OPM during the pandemic.
We used data collected between February 2020 and February 2022 for previously published
reports, as well as additional data collected for this review between July 2022 and May 2023.
Data Sources.  Our review used multiple sources of data, including:
•	 survey data from VHA facilities to report occupational shortages and reasons for those
shortages;
•	 interviews with 18 VISN directors to report examples of impacts of occupational shortages;
and
•	 additional data, such as VHA guidance and fact sheets to identify mitigation strategies used by
the VHA to recruit, retain, and reduce burnout of employees within the VHA.
Methodology.
Survey Development and Distribution
For the annual determination of VHA’s occupational staffing shortages summarized in this report,
we conducted surveys to identify severe occupational staffing shortages at each facility across VHA.
VHA-identified facility points of contact reported severe occupational staffing shortages as defined
in 5 Code of Federal Regulations (C.F.R.) Section (§) 337.204.
The survey listed occupations categorized by: (1) OPM occupational series codes, (2) VHA
assignment codes, and (3) clinical or nonclinical designation.72 We further categorized the
occupations into three groups (medical officer, nurse, and other occupation) to facilitate

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identification of VHA assignment codes and titles for medical officer and nurse. We requested,
and the VHA provided, the points of contact who would be completing the survey on behalf of the
facility.73 Facility points of contact used a drop-down list within the survey to identify all occupations
they considered severe occupational staffing shortages.74 Facility points of contact also had the
option to report that they did not consider any of the occupations as severe occupational staffing
shortages. We reviewed submissions as received and, when necessary, worked with the facility
points of contact to clarify responses and answer questions.
Survey Analysis
We identified an occupation as a severe occupational staffing shortage when it was designated
as such by the VHA-identified facility point of contact. We counted the total number of times
the occupation was identified as a severe occupational staffing shortage across all facilities to
determine shortages across the VHA.
We derived the frequency of severe occupational shortages for medical officer and nurse
because facility points of contact could identify severe shortages at the OPM occupational series
level, VHA assignment code level, or both. As a result, we considered medical officer and nurse
severe occupational staffing shortages if the facility points of contact indicated either the OPM
occupational series or any of the related VHA assignment codes as shortages.75
We used Braun and Clarke’s thematic analysis approach to generate themes for the free text
responses received in the survey.76 Upon initial review of the data, we discovered that many of the
responses were brief and lacked detail thereby making it difficult to understand the underlying
meaning in the free text responses. As a result, we analyzed the data for content, not meaning.
Additionally, some facilities designated multiple reasons for a given occupational shortage, while
other facilities provided only one reason per occupational shortage.
We derived theme assignments for the medical officer and nurse occupations because the survey
was constructed to allow responses at the OPM occupational series level, the VHA assignment code
level, or both. We assigned a theme to one of these occupations if the theme showed up either at
the occupational series or VHA assignment code level. For example, if “Lack of qualified applicants”
was the theme for how a facility determined that Medical Officer (an OPM occupational series job
title) and Psychiatry (a VHA assignment code job title falling under Medical Officer) were both severe
occupational staffing shortages, “Lack of qualified applicants” would be counted once for the theme
in Medical Officer.
We did not assess the validity of the survey responses.
Interviews
In addition to the annual surveys, We conducted interviews with all 18 VISN directors between
October 15, 2020, and November 10, 2020, to review hiring during the pandemic.

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  Appendix
We did not assess the validity of the responses provided in the interviews.
Section 2: Limitations
The shortages discussed in this review represent the frequency of occupations designated as a
severe occupational shortage in the VA OIG’s annual surveys as defined by 5 C.F.R. Section (§)
337.204, but they do not necessarily represent vacancies and should not be considered the sole
measure of VHA-wide severe occupational shortages.77 A severe occupational shortage refers to
particular occupations that are difficult to fill, whereas vacancy refers to an unoccupied position
and is distinct from the designation of a severe occupational shortage. For example, a facility could
identify an occupation as a severe occupational shortage, which could have no vacant positions
or 100 vacant positions. Defining shortages in this manner does not account for other dimensions
that could be used to determine shortages such as the priority of a severe occupational shortage at
a given facility. For example, one facility may consider an occupation as its number one shortage,
while another facility may consider that same occupation as its number 30 shortage. Facility priority
was not considered when determining the frequency of occupations being reported as severe
occupational shortages across the VHA. Further, the impact that reducing a shortage might have on
a facility cannot be assessed by the survey results.
Section 3: Standards
We conducted the review in accordance with Quality Standards for Inspection and Evaluation
published by the Council of the Inspectors General on Integrity and Efficiency.

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APPENDIX D:
Department of Health
and Human Services
Section 1. Methodology
Scope. As of July 1, 2022, there were 15,178 Medicare– and Medicaid–certified nursing homes
nationwide. Our review focused on the staffing experiences at these nursing homes from April 1,
2019, through September 11, 2022 (audit period).
We conducted our audit from July 2022 to January 2023.
Data Sources. We used nursing home staffing shortage data that nursing homes report weekly
to CDC’s NHSN to identify the number of nursing homes that reported a staffing shortage for the
weeks ended May 24, 2020, through September 11, 2022, and to nonstatistically select nursing
homes from which to interview officials about their experiences with staffing shortages before and
during the pandemic. We also used nursing home staffing data that nursing homes report quarterly
in CMS’s PBJ system to analyze the number of hours that nursing home staff worked during the
quarters ended June 30, 2019, through June 30, 2022. In addition, we obtained verbal testimony
from officials from the nonstatistically selected nursing homes.
Methodology. We reviewed staffing shortage data that nursing homes reported weekly to CDC’s
NHSN for the weeks ended May 24, 2020, through September 11, 2022, and staffing data that
nursing homes reported quarterly in CMS’s PBJ system for the quarters ended June 30, 2019,
through June 30, 2022.
From the 3,556 nursing homes that reported a staffing shortage in at least one of the four
categories of nursing home staff (nurses, clinical staff, aides, or other staff) for the week ended July
10, 2022, we nonstatistically selected 50 nursing homes in 44 states. To select the nursing homes,
we considered factors, such as the number of weeks that nursing homes reported a shortage
(during the weeks ended May 24, 2020, through July 10, 2022) and the locations of the nursing
homes.
We interviewed officials, such as nursing home administrators and directors of nursing, from the
selected nursing homes during the period August 17, 2022, through September 13, 2022, to
understand the nursing homes’ experiences with shortages of health care personnel. During each
interview, we requested that the nursing home officials speak about their staffing experiences

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  Appendix
through a series of open-ended questions focused on the positions that were most affected by the
staffing shortages; reasons for the shortages; impact that the shortages had on the nursing home’s
staff, operations, and residents; and actions that the nursing home took to address the shortages
and minimize staff burnout. The blue dots on the map in Exhibit 1 show the locations of the 50
nonstatistically selected nursing homes.
Exhibit 1: Locations of the 50 Nonstatistically Selected Nursing Homes
Source: The HHS OIG.
We also discussed with CMS officials their oversight of nursing home staffing and actions that CMS
took to help nursing homes lessen the impact of staffing shortages during the pandemic.
Section 2: Limitations
A limitation of using staffing shortage data and staffing information reported by nursing homes is
that some nursing homes may not have submitted the required data or the submitted data may not
have passed CMS’s or CDC’s quality assurance checks. Our review did not include an assessment
of nursing homes’ compliance with the requirements to report staffing shortage data or staffing
information, CMS’s oversight of nursing homes’ compliance with these requirements, or the

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  Appendix
accuracy of the shortage data or staffing information that nursing homes reported to the NHSN and
reported in the PBJ system. As a result, we did not assess the nursing homes’ or CMS’s internal
controls related to these requirements.
Additionally, the reasons for the 50 nonstatistically selected nursing homes’ staffing shortages and
the impacts of those shortages as stated in this report reflect the nursing homes’ experiences and
perceptions as they were conveyed to us. We did not verify the accuracy of the information that
nursing home officials provided, obtain perspectives from existing or former nursing home staff, or
corroborate the impact that staffing shortages had on the selected nursing homes. Further, nursing
home officials may not have shared with us all of the reasons for staffing shortages at their nursing
homes, the impacts of the shortages, or their efforts to attract and retain staff or minimize staff
burnout. Therefore, the information in this report may not represent everything that nursing homes
experienced, or all the actions they took during the audit period. This information is provided for
informational purposes only and, therefore, we did not provide any recommendations.
Section 3: Standards
We conducted this review in accordance with generally accepted government auditing standards
issued by the Government Accountability Office.

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95
APPENDIX E:
Shortages Reported by at Least
20 Percent of VHA Facilities
Table 1: Frequency of Most Common Facility-Designated Severe Occupational Shortages, FY 2020
Occupational Series
or Assignment
Codesb
Occupation
Clinical or
Nonclinical
Number of Facilities That
Identified the Occupation
as a Severe Shortage
31
Psychiatrya
Clinical
83
3566
Custodial Worker
Nonclinical
65
0083
Police
Nonclinical
62
P1
Primary Carea
Clinical
51
0620
Practical Nurse
Clinical
49
0801
General Engineering
Nonclinical
48
0180
Psychology
Clinical
47
0644
Medical Technologist
Clinical
45
25
Gastroenterologya
Clinical
41
7408
Food Service Worker
Nonclinical
37
0679
Medical Support Assistance
Nonclinical
36
88
RN Staff Nurse-Inpatientb
Clinical
36
K6a
Hospitalist
Clinical
34
0647
Diagnostic Radiologic Technologist
Clinical
33
N4
Nurse Practitioner – Mental Health/
Substance Use Disorderb
Clinical
31
Q6
RN/Staff-Inpatient Community Living
Centerb
Clinical
31
0201
Human Resources Management
Nonclinical
30
Source: VA OIG analysis of VHA facilities’ responses to the VA OIG’s FY 2020 staffing survey.
a.	 Assignment codes within the Medical Officer occupational series.
b.	 Assignment codes within the Nurse occupational series.
Note: Only occupations designated by at least 20 percent of the facilities were included in this table.

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  Appendix
Table 2: Frequency of Most Common Facility-Designated Severe Occupational Personnel
Shortages, FY 2021
Occupational Series
or Assignment
Codesb
Occupation
Clinical or
Nonclinical
Number of Facilities That
Identified the Occupation
as a Severe Shortage
31
Psychiatrya
Clinical
70
0679
Medical Support Assistance
Nonclinical
62
0083
Police
Nonclinical
60
0180
Psychology
Clinical
60
3566
Custodial Worker
Nonclinical
59
P1
Primary Carea
Clinical
57
0620
Practical Nurse
Clinical
51
0644
Medical Technologist
Clinical
50
0801
General Engineering
Nonclinical
45
7408
Food Service Worker
Nonclinical
40
0647
Diagnostic Radiologic Technologist
Clinical
34
0858
Biomedical Engineering
Nonclinical
32
0675
Medical Records Technician
Nonclinical
31
12
Urologya
Clinical
31
0185
Social Work
Clinical
30
0645
Medical Technician
Clinical
30
25
Gastroenterologya
Clinical
30
0621
Nursing Assistant
Clinical
28
88
RN Staff Nurse-Inpatientb
Clinical
28
Source: VA OIG analysis of VHA facilities’ responses to the VA OIG’s FY 2021 staffing survey.
a.	 Assignment codes within the Medical Officer occupational series.
b.	 Assignment codes within the Nurse occupational series.
Note: Only occupations designated by at least 20 percent of the facilities were included in this table.

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  Appendix
Table 3: Frequency of Most Common Facility-Designated Severe Occupational Shortages, FY 2022
Occupational Series
or Assignment
Codesb
Occupation
Clinical or
Nonclinical
Number of Facilities That
Identified the Occupation
as a Severe Shortage
3566
Custodial Worker
Nonclinical
96
0679
Medical Support Assistance
Nonclinical
88
0620
Practical Nurse
Clinical
86
0180
Psychology
Clinical
73
31
Psychiatrya
Clinical
71
0644
Medical Technologist
Clinical
65
0083
Police
Nonclinical
62
7408
Food Service Worker
Nonclinical
60
P1
Primary Carea
Clinical
60
0801
General Engineering
Nonclinical
54
0621
Nursing Assistant
Clinical
53
88
RN Staff Nurse-Inpatientb
Clinical
51
0185
Social Work
Clinical
44
0647
Diagnostic Radiologic Technologist
Clinical
36
0649
Medical Instrument Technician
Clinical
36
CM
RN Staff-Critical Careb
Clinical
36
Q6
RN/Staff-Inpatient Community Living
Centerb
Clinical
33
CR
RN Staff-Emergency Dept/Urgent Careb
Clinical
32
0645
Medical Technician
Clinical
30
CQ
RN Staff-Inpatient Mental Healthb
Clinical
30
25
Gastroenterologya
Clinical
30
0858
Biomedical Engineering
Nonclinical
29
Source: VA OIG analysis of VHA facilities’ responses to the VA OIG’s FY 2022 staffing survey
a.	 Assignment codes within the Medical Officer occupational series.
b.	 Assignment codes within the Nurse occupational series.
Note: Only occupations designated by at least 20 percent of the facilities were included in this table.

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  Endnotes
Endnotes
1
Medical officers are positions with duties that advise on, administer, supervise, or perform professional and
scientific work in one or more fields of medicine, and when the degree of Doctor of Medicine or Doctor of
Osteopathy is a fundamental requirement.
2
There are only 96 BOP facilities represented here because the 97th facility, FCC Beaumont, relies solely on
contracted clinical staff, who were not included in the scope of this review.
3
A licensed vocational nurse position does not require full professional nurse education.
4
Title 38, United States Code, Veterans’ Benefits, enacted September 2, 1958, includes a special pay authority
used to recruit and retain employees in certain health care occupations.
5
Delegation Agreement, U.S. Office of Personnel Management and Department of Defense, effective July 1, 2012,
and U.S. Office of Personnel Management Title 38 Delegation Agreement with Department of Justice, effective
June 30, 2014.
6
Medical officers are positions with duties that advise on, administer, supervise, or perform professional and
scientific work in one or more fields of medicine, and when the degree of Doctor of Medicine or Doctor of
Osteopathy is a fundamental requirement.
7
The NHSN is a CDC system for tracking health-care-associated infections. Nursing homes are required to report
COVID-19-related data to the NHSN on a weekly basis. The PBJ system is a CMS system designed to collect
staffing information, including the category of work for each person who provides direct care and services to
residents and information on hours of care provided by each category of staff per resident, per day from nursing
homes on a quarterly basis.
8
TRICARE regional contracts provide health care services and support beyond what is available at military hospitals
and clinics.
9
Public Law 115-232, John S. McCain National Defense Authorization Act for Fiscal Year 2019, August 13, 2018;
Public Law 114-328, National Defense Authorization Act for Fiscal Year 2017, December 23, 2016.
10
DOD’s response to House Report 116-442, page 150, accompanying H.R. 6395, the William M. (Mac) Thornberry
National Defense Authorization Act for Fiscal Year 2021 on Behavioral Health Requirements of the Department of
Defense.
11
DOD OIG Report No. DODIG-2022-081, “Evaluation of Department of Defense Military Medical Treatment Facility
Challenges During the Coronavirus Disease-2019 (COVID-19) Pandemic in Fiscal Year 2021,” April 5, 2022.
12
DOD clinical personnel are DOD health care providers that provide medical and other patient care services to DOD
beneficiaries. DOD nonclinical personnel are in administrative, logistical, or clerical positions that are not involved
in direct patient care.
13
DOD OIG Report No. DODIG-2022-081, “Evaluation of Department of Defense Military Medical Treatment Facility
Challenges During the Coronavirus Disease-2019 (COVID-19) Pandemic in Fiscal Year 2021,” April 5, 2022.
14
Although these positions were the highest reported by the MTF personnel, positions may be underreported
because military occupational specialties for Service members did not easily translate to the occupational series
for civilian personnel established by the OPM.
15
DOD Instruction 1400.25, Volume 543, “DOD Civilian Personnel Management System: DOD Civilian Physicians
and Dentists Pay Plan,” February 12, 2018, requires that the sum of payments subject to the Executive Level I
annual limitation plus market pay will not exceed the annual salary of the President of the United States, excluding
expenses, established by Section 102 of title 3, United States Code.  Section 102, title 3, United States Code,
Compensation of the President, establishes that the President shall be paid monthly for compensation in the
aggregate amount of $400,000 a year, for services during the elected term.
16
A “grade” refers to the General Schedule (GS) pay scale, or the pay level for the job. Title 38, United States Code,
Veterans’ Benefits.
17
A common access card is used as an identification badge, or a standard identification card used to physically
access buildings and access DOD computer networks and systems.

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  Endnotes
18
Report No. DODIG-2022-081, “Evaluation of Department of Defense Military Medical Treatment Facility Challenges
During the Coronavirus Disease–2019 (COVID–19) Pandemic in Fiscal Year 2021,” April 5, 2022.
19
A contract discrepancy report is used to record contract discrepancies or problems when contractor performance
is judged unsatisfactory.
20
Operation Allies Welcome assisted vulnerable Afghan nationals, to include those who worked alongside the United
States in Afghanistan for the past two decades, as they safely resettled in the United States.
21
DOD Instruction 1400.25, Volume 1230, “DOD Civilian Personnel Management System: Employment in Foreign
Areas and Employee Return Rights,” July 26, 2012 (Incorporating Change 1, July 29, 2022).
22
Exceptional Family Member Program is a process that documents and evaluates the medical and educational
needs of family members to determine whether the family member can be supported at a specific location.
23
The Joint Outpatient Experience Survey collects data on beneficiary views of outpatient care recently received at
the MTF.
24
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or risk
thereof, while an adverse event is an unintended occurrence or condition associated with care or services that
reach the patient and that may or may not result in harm to the patient.
25
Federal inmates in BOP custody are also housed in residential reentry centers (halfway houses) or in home
confinement; inmates in these settings receive medical care from community providers. Previously, the BOP also
housed some inmates in privately-operated prisons, which were responsible for providing health care to those
inmates; however, in November 2022, the BOP ended its use of privately-operated prisons to house inmates in
compliance with Executive Order 14006 which eliminated the use of these facilities.
26
The Commissioned Corps of the U.S. Public Health Service is a branch of the uniformed services committed to the
service of health. Officers serve in agencies across the Federal Government.
27
Other clinical positions include social workers, dental hygienists and assistants, physical and occupational
therapists, and radiologic technologists. Other nonclinical positions include medical supply technicians, and
additional administrative and support roles.
28
See Department of Justice Office of the Inspector General, “Review of the Federal Bureau of Prisons’ Medical
Staffing Challenges,” Evaluation and Inspections Division 16-02 (March 2016).
29
Department of Justice Office of the Inspector General, “Remote Inspection of Federal Correctional Institution
Milan,” Evaluation and Inspections Division 21-032 (January 2021).
30
Department of Justice Office of the Inspector General, Inmate Perceptions of the Federal Bureau of Prisons’
Management of the Coronavirus Disease 2019 Pandemic, Evaluation and Inspections Division 23-067 (May
2023).
31
Department of Justice Office of the Inspector General, “Staff Perceptions of the Federal Bureau of Prisons’
Management of the Coronavirus Disease 2019 Pandemic: A Follow-Up Survey of BOP Staff,” Evaluation and
Inspections Division 21-126 (September 2021).
32
The U.S. OPM granted BOP direct hire authorities for five health care occupational series: 0610 (nurse),
0620 (licensed practical nurse), 0602 (medical officer), 0660 (pharmacist), and 0647 (diagnostic radiologic
technologist).
33
VA medical benefits package includes inpatient and outpatient care, primary and specialty care, preventive care,
diagnostic and treatment services, long term care, mental health care, pharmacy benefits, and other services.
https://www.va.gov/healthbenefits/resources/publications/hbco/hbco_medical_benefits_package.asp (The
website was accessed April 29, 2022).
34
VHA, Coronavirus Disease 2019 (COVID-19) Response Report, October 27, 2020, states, “In emergency situations,
VA avails itself to national, state, territorial, tribal, and local [civilian] governments to prepare and support relief
efforts. This service is known as VA’s Fourth Mission.”
35
Veterans Access, Choice, and Accountability Act of 2014, Pub. L. No. 113-146, 128 Stat. 1754 (2014).
36
VA Choice and Quality Employment Act, Pub. L. No. 115-46, 131 (2017).

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  Endnotes
37
VA OIG: OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, Fiscal Year
2020, Report No. 20-01249-259, September 23, 2020; OIG Determination of Veterans Health Administration’s
Occupational Staffing Shortages, Fiscal Year 2021, Report No. 21-01357-271, September 28, 2021; OIG
Determination of Veterans Health Administration’s Occupational Staffing Shortages, FY 2022, Report No. 22-
00722-187, July 7, 2022.
38
Seven facilities reported no severe occupational staffing shortages in FY 2020, which dropped to three in FY
2021.
39
The VA OIG counted the number of times a theme showed up for each of the top five clinical and top five
nonclinical occupations.
40
Some facilities designated multiple reasons for a given occupational shortage, while other facilities provided only
one reason per occupational shortage resulting in the sum of the percentage of responses exceeding 100 percent.
41
Department of Veterans Affairs Functional Organizational Manual Version 7.0, 2021. Operational control of VHA
facilities is organized under 18 VISNs, intended as “shared system(s) of care working together to better meet local
health care needs and provide Veterans greater access to care.”
42
VA OIG: OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, Report No.
15-00430-103, January 30, 2015; OIG Determination of Veterans Health Administration’s Occupational Staffing
Shortages, Report No. 15-03063-511, September 1, 2015; OIG Determination of VHA Occupational Staffing
Shortages, Report No. 16-00351-453, September 28, 2016; OIG Determination of VHA Occupational Staffing
Shortages, FY 2017, Report No. 17-00936-385, September 27, 2017; OIG Determination of Veterans Health
Administration’s Occupational Staffing Shortages, FY 2018, Report No. 18-01693-196, June 14, 2018; OIG
Determination of Veterans Health Administration’s Occupational Staffing Shortages, FY 2019, Report No. 19-
00346-241, September 30, 2019; OIG Determination of Veterans Health Administration’s Occupational Staffing
Shortages, Fiscal Year 2020, Report No. 20-01249-259, September 23, 2020; OIG Determination of Veterans
Health Administration’s Occupational Staffing Shortages, Fiscal Year 2021, Report No. 21-01357-271, September
28, 2021; OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, FY 2022,
Report No. 22-00722-187, July 7, 2022.
43
ECRI, “ECRI Reports Staffing Shortages and Clinician Mental Health are Top Threats to Patient Safety,” news
release March 14, 2022, https://www.ecri.org/press/ecri-reports-staffing-shortages-and-clinician-mental-health-
are-top-threats.
44
“Strategies to Mitigate Health care Personnel Staffing Shortages,” CDC, accessed January 27, 2023 www.cdc.gov/
coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html.
45
GAO, Veterans Health Care Staffing Challenges Persist for Fully Integrating Mental Health and Primary Care
Services, GAO-23-105372, December 15, 2022.
46
PRAC, Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the
Pandemic (as reported by Offices of Inspectors General across government) (Washington, D.C.; December 2022).
47
VA OIG, Review of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19
Pandemic, Report No. 20-02794, Awaiting Publication.
48
VA OIG, Appointment Management During the COVID-19 Pandemic, Report No. 20-02794-218, September 1,
2020.
49
COVID-19 Response Plan, Incident-specific Annex to the VHA High Consequence Infection (HCI) Base Plan, March
23, 2020.
50
Various available direct hire authorities as discussed allow for the noncompetitive appointments in certain
shortage occupations notwithstanding competitive service and preference eligibility standards.
51
5 U.S.C. § 3304.
52
38 U.S.C. § 7412.
53
Veterans Health Administration COVID-19 Operational Plan, Version 1.5, January 27, 2023.
54
The CDT program, targeted for implementation in quarter four of FY 2023, was influenced by the COVID-19
pandemic to support internal and Fourth Mission emergencies and disasters and will be composed of 360
permanent deployment-ready clinical staff trained in emergency response.

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  Endnotes
55
VHA’s DEMPS program uses a database of volunteer clinical and nonclinical staff who are matched and deployed
to meet the needs of internal and external Fourth Mission emergency response missions.
56
Coronavirus Aid, Relief, and Economic Security Act of 2020, Pub. L. No. 116-136 (2020).
57
VA Nurse and Physician Assistant RAISE Act Pub L. No 117–103, 136 Stat. 822. (2022).
58
Honoring our PACT Act of 2022 Pub. L. 117-168, 136 Stat. 1808, (2022).
59
VHA Reduce Employee Burnout and Optimizing Organizational Thriving (REBOOT), Reducing Employee Burnout
Fact Sheet, March 3, 2022 (www.va.gov/HEALTH/docs/REBOOT_Task_Force_Fact_Sheet_030122_508.pdf).
60
Medicaid is a state-run program that is jointly funded and administered by the Federal and state governments.
Although each state has considerable flexibility in designing and operating its Medicaid program, it must comply
with applicable federal requirements.
61
Nursing homes are required to comply with health and safety requirements in federal regulations (42 C.F.R part
483, subpart b) to participate in the Medicare and Medicaid programs. The list of nursing homes was downloaded
from CMS’s provider data catalog at https://data.cms.gov/provider-data/archived-data/nursing-homes. Accessed
on September 20, 2022.
62
This data may vary from week to week because nursing homes have the opportunity to submit corrected data for
previously-reported weeks. Available at https://data.cms.gov/covid-19/covid-19-nursing-home-data. Accessed on
September 29, 2022.
63
HHS Assistant Secretary for Planning and Evaluation, Behavioral Health, Disability, and Aging Policy; COVID-19
Intensifies Nursing Home Workforce Challenges; October 18, 2020. Available at https://aspe.hhs.gov/reports/
covid-19-intensifies-nursing-home-workforce-challenges. Accessed on December 12, 2022.
64
CMS required nursing homes to report staffing shortages and other COVID-19 facility data beginning with the week
ended May 17, 2020, to support surveillance of COVID-19 cases and increase transparency for nursing home
residents, their representatives, and their families. CMS memo to state survey agency directors, QSO-20-29-NH
(May 6, 2020); 42 C.F.R § 483.80(g).
65
Direct care staff are those individuals who, through interpersonal contact with residents or resident care
management, provide care and services to residents to allow them to attain or maintain the highest practicable
physical, mental, and psychosocial well-being. See 42 C.F.R § 483.70(q)(1). 42 C.F.R § 483.70(q)(2).
66
CMS, “Electronic Staffing Data Submission Payroll-based Journal Long-term Care Facility Policy Manual,” version
2.6, June 2022. Available at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/
nursinghomequalityinits/downloads/pbj-policy-manual-final-v25-11-19-2018.pdf. Accessed on June 3, 2022.
67
The average daily number of hours worked by clinical staff per nursing home decreased by .1 hour, or 6 minutes.
68
A list of enacted waivers specific to nursing homes and their current status can be found at: https://www.cms.gov/
files/document/long-term-care-facilities-cms-flexibilities-fight-covid-19.pdf. Accessed on June 21, 2022.
69
Public Law 115-232, John S. McCain National Defense Authorization Act for Fiscal Year 2019, August 13, 2018;
Public Law 114-328, National Defense Authorization Act for Fiscal Year 2017, December 23, 2016.
70
VA Choice and Quality Employment Act, Pub. L. No. 115-46, 131 (2017).
71
The Manila station was excluded, beginning with the OIG Determination of Veterans Health Administration
Occupational Staffing Shortages, FY 2018 report, as its staff were not composed VA employees but employed by
the State Department and were foreign nationals.
72
The list of 489 occupations included those provided by VHA Workforce Management and Consulting and
historically used in prior OIG Determination of VHA’s Occupational Staffing Shortages reports. This list included
occupations VHA facilities did not have staff in at the time of the reviews. These occupations were included
because facilities have previously identified severe staffing shortages in occupations without any staff. Separately,
VHA reported that some occupations included in the surveys were consolidated at the VISN level, national level, or
may have been employed at both the facility and VISN levels.
73
Prior to the OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, FY 2021,
Report No. 21-01357-271, September 28, 2021 report, medical center directors were asked to submit the survey
on behalf of their facility.

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  Endnotes
74
Hiring authority for the respective occupations populated in the survey as severe occupational staffing shortages
were identified.
75
For purposes of this report, we used the term occupation when referencing either OPM occupational series or VHA
assignment codes.
76
Virginia Braun and Victoria Clarke, “Using thematic analysis in psychology,” Qualitative Research in Psychology,
3(2), 77–101. July 2006.
77
5 C.F.R. § 337.204, Severe Shortage of Candidates, states:
  (a) OPM will determine when a severe shortage of candidates exists for particular occupations, grades (or equivalent),
and/or geographic locations. OPM may decide independently that such a shortage exists, or may make this
decision in response to a written request from an agency.
  (b) An agency when requesting direct-hire authority under this section, or OPM when deciding independently, must
identify the position or positions that are difficult to fill and must provide supporting evidence that demonstrates
the existence of a severe shortage of candidates with respect to the position(s). The evidence should include, as
applicable, information about:
  (1) The results of workforce planning and analysis;
  (2) Employment trends including the local or national labor market;
  (3) The existence of nationwide or geographic skills shortages;
  (4) Agency efforts, including recruitment initiatives, use of other appointing authorities (e.g., schedule A, schedule B)
and flexibilities, training and development programs tailored to the position(s), and an explanation of why these
recruitment and training efforts have not been sufficient;
  (5) The availability and quality of candidates;
  (6) The desirability of the geographic location of the position(s);
  (7) The desirability of the duties and/or work environment associated with the position(s); and
  (8) Other pertinent information such as selective placement factors or other special requirements of the position, as
well as agency use of hiring flexibilities such as recruitment or retention allowances or special salary rates.

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 Acknowledgements
Acknowledgements
This report was prepared under the guidance of the PRAC Health Care Subgroup, chaired by HHS
Inspector General, Christi A. Grimm and led by the DOD OIG in collaboration with the DOJ OIG,
VA OIG, and HHS OIG professional staff. Special acknowledgments to the following staff who
collaborated on this report:
DOD OIG:
James Degaraff
Bridgett Fowler
Kristine Do
Glenn Estrada
Isaac Gallardo Recano
Katelyn Potter
DOJ OIG:
DOJ OIG team
VA OIG:
Jennifer Baptiste, MD
Julie Kroviak, MD
Patrice Marcarelli, MD
David Vibe, MBA
John Wallis
HHS OIG:
Pat Cogley
John Beacham
Lori Ahlstrand
Gerald Illies
Lydia Barbour
Jane Wines
Vlada Hutton
Richard Mills
Jessica Swanstrom
PRAC:
Jarrett Fussell
Aaron Jewell
Lisa Reijula
Amanda Seese
Jenniffer Wilson

For more information:
Department of Defense,
Office of Inspector General
Office of Public Affairs
Public.Affairs@dodig.mil
Department of Justice,
Office of Inspector General
Stephanie Logan, Communications Director
Stephanie.Logan@usdoj.gov
Department of Veterans Affairs,
Office of Inspector General
Fred Baker, Public Affairs Officer
Fred.Baker@va.gov
Department of Health and Human Services,
Office of Inspector General
Office of Public Affairs
Public.Affairs@oig.hhs.gov
Pandemic Response Accountability Committee
Lisa Reijula, Associate Director of Outreach and Engagement
Lisa.Reijula@cigie.gov
Visit us at:
PandemicOversight.gov
Follow us at:
Report Fraud, Waste, Abuse, or Misconduct:
To report allegations of fraud, waste, abuse, or misconduct regarding
pandemic relief funds or programs please go to the PRAC website at
PandemicOversight.gov.
A Committee of the
Council of the Inspectors General
on Integrity and Efficiency

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