[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
``CORRECTING `KERFUFFLES' - ANALYZING PROHIBITED PRACTICES AND
PREVENTABLE PATIENT DEATHS AT JACKSON VAMC''
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
Wednesday November 13, 2013
__________
Serial No. 113-44
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Minority Member
DAVID P. ROE, Tennessee CORRINE BROWN, Florida
BILL FLORES, Texas MARK TAKANO, California
JEFF DENHAM, California JULIA BROWNLEY, California
JON RUNYAN, New Jersey DINA TITUS, Nevada
DAN BENISHEK, Michigan ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MARK E. AMODEI, Nevada GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
Jon Towers, Staff Director
______
Subcommittee on Oversight and Investigations
MIKE COFFMAN, Colorado, Chairman
DOUG LAMBORN, Colorado ANN KIRKPATRICK, Arizona, Ranking
DAVID P. ROE, Tennessee Minority Member
TIM HUELSKAMP, Kansas MARK TAKANO, California
DAN BENISHEK, Michigan ANN M. KUSTER, New Hampshire
JACKIE WALORSKI, Indiana BETO O'ROURKE, Texas
TIMOTHY J. WALZ, Minnesota
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Page
November 13, 2013
``Correcting `Kerfuffles' - Analyzing Prohibited Practices And
Preventable Patient Deaths At Jackson VAMC'' 1
OPENING STATEMENT
Hon. Mike Coffman, Chairman 1
Hon. Ann Kirkpatrick, Ranking Minority Member 3
WITNESSES
Ms. Phyllis Hollenbeck, Former Physician of Family Medicine, G.V.
Sonny Montgomery VA Medical Center
Oral Statement............................................... 4
Prepared Statement........................................... 5
Dr. Charles Sherwood, M.D., Former Chief of Ophthalmology, G.V.
(Sonny) Montgomery VA Medical Center
Oral Statement............................................... 7
Prepared Statement........................................... 8
Erik Hearon, Maj. Gen. (Ret), United States Air Force
Oral Statement............................................... 18
Prepared Statement........................................... 19
Mr. Charles Jenkins, President American Federation of Government
Employees, Local 589
Oral Statement............................................... 29
Prepared Statement........................................... 30
Additional Statement......................................... 31
Ms. Rica Lewis-Payton, Network Director of VISN-16 G.V. (Sonny)
Montgomery VA Medical Center,
Oral Statement............................................... 59
Prepared Statement........................................... 61
Accompanied by:
Dr. Gregg Parker, M.D.
Mr. Joe Battle
APPENDIX
Comments on Veteran Affairs Report of July 2012, WhistleBlower
Complaints..................................................... 82
Questions for the Record......................................... 122
``CORRECTING `KERFUFFLES' - ANALYZING PROHIBITED PRACTICES AND
PREVENTABLE PATIENT DEATHS AT JACKSON VAMC''
----------
Wednesday, November 13, 2013
House of Representatives
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
Washington, D.C.
The subcommittee met, pursuant to notice, at 10:05 a.m., in
Room 334, Cannon House Office Building, Hon. Mike Coffman
[chairman of the subcommittee] presiding.
OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN
Present: Representatives Coffman, Roe, Huelskamp, Benishek,
Kirkpatrick, and Walz.
Also Present: Representatives Palazzo, Harper, and
Thompson.
Mr. Coffman. Good morning. This hearing will come to order.
I want to welcome everyone to today's hearing titled
``Correcting `Kerfuffles' - Analyzing Prohibited Practices and
Preventable Patient Deaths at Jackson VAMC.''
I would also like to ask unanimous consent that several of
our Mississippi colleagues be allowed to join us here on the
dais to address issues very specific to their constituents.
Hearing no objection, so ordered.
Today's hearing is based on serious allegations of
wrongdoing at the G.V. Sonny Montgomery VA Medical Center in
Jackson, Mississippi. Despite systematic problems at Jackson,
VA has maintained that any concerns have not had a negative
effect on patient care.
For example, the VA under secretary for Health, Dr. Robert
Petzel, made the following statement in an apparent attempt to
downplay the myriad issues at Jackson VAMC.
[Video shown.]
Mr. Coffman. Kerfuffles, that is a new word for me having
been from the army and the marine corps. I do not think it was
something in our lexicon. I do not think we are going to go
there.
This clip represents the attitude of VA following years of
prohibited practices at Jackson that have negatively affected
care provided to veterans. That negative effect is apparent in
the tragic story of Johnny Lee. Johnny Lee, an army veteran and
long-time employee of Jackson VAMC, became a casualty of inept
supervision and inadequate staffing on the part of the facility
officials.
According to whistler blower reports, Mr. Lee went to
Jackson VAMC for a routine skin graft operation in April of
2011. Following the operation, he was attached to a negative
pressure wound therapy machine, often referred to as a wound
vac, that is designed to remove fluids from sealed wounds.
Mr. Lee was then left unattended and connected to the wound
vac for a number of hours. When Jackson personnel finally
returned to check on him, he was dead, his body having been
drained of all its blood, which spilled out on to the floor of
the room.
Months prior to this horrible incident, the FDA released a
safety report on wound vacs requiring frequent monitoring of
patients with a specific caveat to, quote, be vigilant for
potentially life-threatening complications such as bleeding and
be prepared to take prompt action if they occur, unquote.
Mr. Lee's death would have certainly been prevented had
Jackson VAMC officials heeded this warning, properly informed
and supervised its personnel, and monitored Mr. Lee
appropriately.
Today we will discuss the many serious issues that continue
to plague Jackson VAMC. Under staffing of personnel has led to
the over-reliance on nurse practitioners, resulting in many
veterans not getting access to an actual doctor during their
care at Jackson and nurse practitioners operating without
supervision.
The routine practice of booking multiple patients for
single appointment slots leads to patients being turned away
without service. Thousands of radiology images have gone unread
or improperly read, resulting in misdiagnosis of serious and in
some cases fatal illnesses. Jackson VAMC management was aware
of these allegations, but only undertook a cursory
investigation to address it.
The facility also has narcotics prescription policies in
place that led to the August 2012 resignation of the Jackson
VAMC chief of staff and the May 2012 arrest of the associate
director for patient care services on a prescription fraud
charge.
Other allegations state that physicians at Jackson VAMC are
frequently asked to sign Medicare home health certificates on
patients they had not seen or for nurse practitioners they had
not supervised which is essentially a commission of Medicare
fraud.
Ultimately VA has taken inadequate action to hold Jackson
VAMC management accountable for contributing to or approving of
these systematic problems.
The Office of Special Counsel appropriately stated that the
VA investigation into these matters has been insufficient and
unreasonable, unquote.
In light of the obvious deficiencies we will discuss today,
some of which have led to preventable patient deaths such as
that of Mr. Lee, it is painfully obvious that VA is not taking
the problems occurring at this facility seriously and is
showing a lack of commitment that quite apparently affects care
provided to veterans.
I now yield to Ranking Member Kirkpatrick for her opening
statement.
OPENING STATEMENT OF ANN KIRKPATRICK, Ranking Minority Member
Mrs. Kirkpatrick. Thank you, Mr. Chairman, for holding this
hearing today.
I am sure we all agree that patient safety and quality of
care are top priorities for this committee. I have been very
concerned with the slew of patient care issues that have been
brought to my attention just this year.
In September, the full committee held a field hearing in
Pittsburgh, Pennsylvania that focused on five of the over 15 VA
medical centers that have recently experienced patient care
issues.
At this hearing, we are going to examine the policies and
response of the Department of Veterans Affairs to several
allegations originating from multiple employees spanning
several years at the G.V. Sonny Montgomery VA Medical Center in
Jackson, Mississippi.
These allegations include but are not limited to under-
staffing of personnel, over-booking of patients, insufficient
medical staff supervision, and improper Medicare certification
and narcotics prescriptions.
I am troubled by the testimony of our first panel. After
reading it and the associated reports, it seems to me that not
much has improved over the years and patients continue to be
subjected to improper care, unsafe conditions, and privacy
violations. This, of course, is unacceptable.
I am equally concerned with what looks like nearly a
complete collapse of the leadership team to hold managers
accountable for improper actions, failures to follow
established procedures, and a blatant disregard for policies
that are in place.
Mr. Chairman, as you know, the Office of Special Counsel,
an independent federal investigative and prosecutorial agency,
raised concern in a March 2013 letter to the President and
Congress about the Jackson VA Medical Center regarding the
numerous whistle blower disclosures made by five employees and
physicians.
In a subsequent letter in September 2013, the Office of
Special Counsel sent another letter to the President explaining
why they had found that the Department of Veterans Affairs'
reports were deficient in the cases concerning the allegations
made by the two physicians, Dr. Hollenbeck and Dr. Sherwood,
both of whom are with us today.
I would like to hear from the VA what is being done to fix
the problems that are being highlighted today and moving
forward, what plan is in place to prevent them from happening
in the future.
Thank you, Mr. Chairman.
Mr. Coffman. Thank you, Ranking Member Kirkpatrick.
I ask that all Members waive their opening remarks as per
this committee's custom.
With that, I invite the first panel to the witness table.
On this panel, we will hear from Dr. Phyllis Hollenbeck, former
physician of family medicine, and Charles Sherwood, former
chief of ophthalmology at Jackson. We will also hear from Major
General Erik Hearon, United States Air Force retired, and Mr.
Charles Jenkins, president of the American Federation of
Government Employees, Local 589.
All of your complete written statements will be made part
of the hearing record.
Dr. Hollenbeck, you are now recognized for five minutes.
STATEMENT OF PHYLLIS HOLLENBECK
Dr. Hollenbeck. Thank you.
Good morning. It is once again an honor and a privilege to
be asked to testify before a committee of the United States
House of Representatives that focuses on the lives of our
precious veterans.
The title of this hearing refers to kerfuffle, a funny
sounding word whose meaning, to throw into disorder, should not
be underestimated.
What I have witnessed in the primary care service at the
G.V. Sonny Montgomery VA Medical Center in Jackson, Mississippi
is a sad, serious, and self-perpetuating state of ugly chaos.
The VA's own investigative team report on my Office of
Special Counsel whistle blower complaint substantiated that the
medical center does not have enough physicians and nurse
practitioners have not had appropriate supervision and
collaboration with physicians.
The lack of required monitoring results in NPs practicing
outside the scope of their licensure. It is crucial to
understand that in all the years that NPs have existed at the
Jackson VA, there was no oversight or review of their clinical
care. Physicians had ongoing quality assurance and peer reviews
done on their work. The NPs had none.
Dorothy Taylor-White oversaw this setup through her power
over patient care services, but Dr. Kent Kirchner, chief of
staff, enabled and agreed to this illegal operation.
And these unsupervised NPs outnumbered the physicians in
primary care by a ratio of three to one and sometimes four to
one.
This same cavalier attitude and laxity by medical center
and VISN leadership towards safe and proper medical care for
the veterans empowered the NPs to prescribe narcotics without
physician supervision and without individual DEA registration
numbers, in flagrant violation of federal and individual state
laws and VA handbook regulations.
A practitioner who never obtained an NP license was the
entire women's health clinic for two decades, writing narcotics
and seeing patients independently.
Scheduling of veterans in a ghost clinic when no provider
was assigned to that clinic, over-booking, double booking, and
inadequate capacity for walk-in visits were all found. Both
administrative and medical leadership were continuously
informed of these issues.
In view of what has happened at Jackson, it is a blessing
that this hearing comes as proposed changes to the VA nursing
handbook have come out. The plan is to make all NPs in the
nationwide VA system operate as fully independent and
unsupervised without regard to state licensure requirements or
scope of practice and not as part of a physician led veterans'
care team.
My current work in the compensation and pension service
allows me to see care from all clinics in the Jackson system.
And this is what I often see from unsupervised NPs. Diagnoses
not made when they should have been. Common stellar examples
are heart disease, diabetes, and asthma. Symptoms are not
addressed or recognized and proper tests and treatments are
delayed.
Even when diagnoses are made, diseases are not monitored or
treated appropriately. Diabetes leads to chronic kidney disease
and then the kidney disease is not noted until far advanced. A
bizarre progress note template used for office visits different
from what physicians use.
The NP does not take an adequate history for the veteran's
current complaints. The same history and physician is cut and
pasted into perpetuity as is the chronic problem including the
diagnosis and billing code for URI, the common cold, forever.
The most compelling case is a veteran who had white blood
cell changes showing the onset and insidious march of chronic
lymphocyte leukemia for ten years and was only diagnosed when
the severe abdominal pain caused by a mass was biopsied.
When I saw him in C&P, he was dying and he and his wife
told me they remembered the shocked look on the face of the
blood specialist when he reviewed the veteran's records.
Veterans suffer needlessly even when they do not die. Think
of the veteran whose fatigue is not just due to his chronic
medical problems but because of a new cardiac arrhythmia. When
the subtlety of that diagnosis is missed by an NP, the veteran
goes home and dies. When the symptom is acknowledged and an EKG
is done, a pacemaker buys a few more years.
Quoting from the classic opening pages of Harrison's
Textbook of Medicine, a seminal part of medical school
education, disease often tells itself in a causal parenthesis.
Skill and diagnosis reflects a way of thinking more than doing.
The content of the record reflects the quality of the care
provided.
My written testimony documents the vast differences in
training and approach to the patient between nurse
practitioners and physicians.
As Americans become sicker and sicker, younger and younger,
and on more and more medicines, the VA proposal shortchanges
the veterans. The care of human beings is too sacred to change
a policy either for monetary or nursing lobby concerns.
The center director, Joe Battle, is fond of reminding us
that while you are at the VA, you are on a reservation. This
translates into federal supremacy, means we do not have to
follow the laws.
It also means that medical and ethical boundaries are
boldly breached. In this case, standing up to the federal
specialness claim and going off the reservation is a sign of
sanity and professionalism.
Duty calls us now as it called the veterans. Thank you.
[THE PREPARED STATEMENT OF PHYLLIS HOLLENBECK]
Good morning. It is once again an honor and a privilege to
be asked to testify before a committee of the US House of
Representatives that focuses on the lives of our precious
Veterans. The title of this hearing refers to ``Kerfuffle'', a
funny-sounding word whose meaning--``to throw into disorder''--
should not be underestimated. What I have witnessed in the
primary care service at the G.V. (Sonny) Montgomery VA Medical
Center in Jackson, Mississippi is a sad, serious, and self-
perpetuating state of ugly chaos.
The VA's own investigative team report on my Office of
Special Counsel Whistleblower Complaint substantiated that
``the Medical Center does not have enough physicians, and nurse
practitioners (NPs) have not had appropriate supervision and
collaboration with Physician Collaborators.'' It states ``NPs
were also erroneously declared as Licensed Independent
Practitioners (LIP), and the required monitoring of their
practice did not consistently occur resulting in NPs practicing
outside the scope of their licensure.'' It is crucial to
understand that in all the years that NPs have existed at the
Jackson VAMC, there was no oversight or review of their
clinical care. Physicians had ongoing quality assurance and
peer reviews done on their work--the NPs had no oversight.
Dorothy Taylor-White oversaw this set-up through her power over
``patient care services'', but Dr. Kent Kirchner, Chief of
Staff, enabled and agreed to this illegal operation. And these
unsupervised NPs outnumbered the physicians in primary care by
a ratio of 3:1, and sometimes 4:1.
This same cavalier attitude and laxity by the Medical
Center and VISN (Veterans Integrated Service Network)
leadership towards safe and proper medical care for the
Veterans empowered the NPs to prescribe narcotics--without
physician supervision--without individual DEA registration
numbers, in flagrant violation of Federal and individual state
laws and VA Handbook regulations. A practitioner who never
obtained an NP license was the entire Women's Health Clinic for
two decades, writing narcotics and seeing patients
independently. ``A clinical care review'' of records where NPs
prescribed controlled substances ``outside of the authority
granted by their licenses'' was called for in the report.
Scheduling of Veterans in a ``ghost'' or ``vesting'' clinic
when no provider was assigned to that clinic, overbooking /
double-booking, and inadequate capacity for walk-in visits were
all found, and all these issues threaten the care of the
Veteran. Both administrative and medical leadership were
continuously informed.
In view of what has happened at Jackson, it is a blessing
that this hearing comes as proposed changes to the VA Nursing
Handbook have come out. The plan is to make all NPs in the
nationwide VA system operate as fully independent and
unsupervised, without regard to state licensure requirements or
scope of practice--not as part of a physician-led Veteran's
care team. My current work in the Compensation and Pension
Service allows me to see care from all clinics in the Jackson
system. And this is what I often see from unsupervised NPs
(exacerbated by clinician turnover and discontinuity of care):
1.) Diagnoses not made when they should have been. Common
stellar examples are heart disease, diabetes, and asthma.
Symptoms aren't addressed or recognized and proper tests/
treatments are delayed.
2.) Even when diagnoses are made, diseases are not
monitored or treated appropriately. Diabetes leads to chronic
kidney disease; and then the kidney disease is not noted until
far advanced.
3.) A bizarre progress note template used for office
visits, different from what physicians use. The NP does not
take an adequate history for the Veteran's current complaints;
the same history and physical is cut and pasted into
perpetuity, as is the chronic problem list--including the
diagnosis and billing code for ``URI''--the common cold.
The most compelling case is a Veteran who had white blood
cell changes showing the onset and insidious march of chronic
lymphocyte leukemia for ten years, and was only diagnosed when
a mass causing severe abdominal pain was biopsied. When I saw
him in C &P he was dying--and he and his wife told me they
remembered the shocked look on the face of the blood specialist
when he reviewed the Veteran's records.
Veterans suffer needlessly even when they don't die. Think
of the Veteran whose ``fatigue'' is not just due to his chronic
medical conditions but because of a new cardiac arrhythmia;
when the subtlety of that diagnosis is missed by an NP the
Veteran goes home and dies. When the symptom is acknowledged
and an EKG is done as it should be, a pacemaker can buy a few
more human life years. Quoting from the classic opening pages
of Harrison's Textbook of Medicine, a seminal part of medical
school education, ``disease often tells itself in a casual
parenthesis . . . skill in diagnosis reflects a way of thinking
more than doing . . . The content of the record . . . reflects
the true quality of the care provided.'' My written testimony
documents the vast differences in training and approach to the
patient between nurse practitioners and physicians; as
Americans become sicker and sicker, younger and younger, and on
more and more medicines the VA proposal shortchanges the
Veterans. The care of human beings is too sacred to change a
policy for either monetary or nursing lobby reasons.
The Center Director, Joe Battle, is fond of reminding us
that ``when you're at the VA, you're on the reservation''; this
translates into Federal Supremacy means ``we don't have to
follow the laws''. It also means that medical and ethical
boundaries are boldly breached. In this case, standing up to
the ``Federal Specialness'' claim, and ``going off the
reservation'', is a sign of sanity and professionalism. Duty
calls us now--as it called the Veterans.
Oral Testimony
House Veterans Affairs Subcommittee
O & I Hearing
November 13, 2013
Phyllis A.M. Hollenbeck MD, FAAFP
Mr. Coffman. Dr. Sherwood, you are now recognized for two
and one-half minutes.
STATEMENT OF CHARLES SHERWOOD
Dr. Sherwood. Thank you, Mr. Chairman and Members of this
committee, for the opportunity to testify today.
My name is Charles Sherwood and I am a recently retired
ophthalmologist with all of my 31 years of service to the VA at
the Jackson VA Medical Center.
The so-called performance-based model for senior executive
service managers was implemented by the Department of Veterans
Affairs in the late 1990s. This compensation model in a
modified form was extended to physicians by a law in 2004 and
was implemented in 2006. The model has been manipulated to
emphasize pay and job security at the expense of health and
safety of patients.
A federal trial demonstrated that a Jackson VA Medical
Center radiologist scored income boosting relative value units
by speed reading radiologic imaging studies. He was not reading
all images in every study for which he provided an
interpretation.
Fifty-two veterans on random reexaminations demonstrated
misses in the radiologic interpretation provided by Dr. Khan.
At least eight misses resulted in inoperable lesions, apparent
cancers. At the trial, the names of the 52 victims was
redacted.
To preserve their management positions, Jackson VA Medical
Center administrators in response to a subpoena have refused to
turn over the medical records of the 52 patients to the
Mississippi Board of Medical Licensure. The State Board of
Medical Licensure is investigating the radiologist who is a
Mississippi licensed physician.
In response to my Office of Special Counsel complaint, the
central office of the Department of Veterans Affairs refused to
order the local Jackson VA Medical Center officials to make
legally required institutional disclosures to injured veterans
and their families. The 50 remaining victims do not even know
they were harmed.
Congressional hearings have focused on performance bonuses
for senior executive service managers. The response to my
Freedom of Information Act requests for senior executive
service compensation did not disclose their retention bonuses.
Physicians under the same compensation model as the senior
executive service are eligible for up to 100 percent of their
salary to be awarded as a retention bonus or a retention
allowance.
I have provided this subcommittee a VISN 16 document
referring to retention allowances for senior executive service
managers.
To understand what actual compensation is being paid to
senior executive service managers, retention bonuses must be
taken into account.
Reform is required to protect patients by adjusting the pay
system and preventing administrators from covering up patient
injury.
I look forward to your questions.
[THE PREPARED STATEMENT OF CHARLES SHERWOOD]
Thank you, Mr. Chairman and members of the subcommittee.
What follows is a continuation of my testimony. My name is
Charles Sherwood. I retired from the VA in May 2011 as a
physician with all of my 31 years of VA service at the G. V.
``Sonny'' Montgomery VA Medical Center. During the past fifteen
years the Jackson VAMC has had a diverse leadership who all
share a common trait, a progressive failure of their moral
compass. The VA has a long and sordid history of intimidation
and retaliation against employees who dare to object to poor
patient care. On March 11, 1999 in this very room, the
Subcommittee on Oversight and Investigations held a hearing
entitled ``Whistleblowing and Retaliation in the Department of
Veterans Affairs''. In his opening remarks, Subcommittee
Chairman Terry Everritt, cited testimony from a 1992 Committee
on Government Operations report (Report 102-1062). He focused
on the section of the 1992 report entitled ''The DVA,
Department of Veterans Affairs, discourages the reporting of
poor quality care by harassing whistleblowers or firing them.''
Chairman Everett paraphrased from that section the words of Tom
Devine, the director of the Government Accountability Project,
who said ``The Department of Veterans Affairs is a leader on
the merit system anti-honor for one simple reason: free speech
repression has been a way of life at this agency''. (Full text
at: http://commdocs.house.gov/committees/vets/hvr031199.000/
hvr031199--0f.htm). I am dismayed to report to you that today,
twenty years later, the leadership culture of the VA is
unchanged with the exception of the improved sophistication
with which it intimidates its employees.
The federal trial, which is the basis for my Office of
Special Counsel complaint and my complaint to the Mississippi
State Board of Medical Licensure, exposed the fact that this
erosion of ethical boundaries is a systemic problem for the VA.
Careerism and the pursuit of personal financial gain by members
of the Senior Executive Service have virtually collapsed
processes designed to assure patient safety. The unbridled
power of these individuals to take whatever measures are
necessary to polish their images and incomes with unrealistic
performance measure data must be curbed. This federal trial
proved that every conceivable level of management from the
Undersecretary for Health to the service chief level were
culpable in failing to protect veterans they are duty bound to
serve. Failure to act against wrongdoing is complicity with it.
The current management officials of VISN 16 and the Jackson
VAMC are acting as a tight knit cabal. They continue to act to
protect and preserve their own power and money at the expense
of patients and employees alike. Despite public exposure and
media attention, there has been no interest from Veterans
Administration Central Office (VACO) to assume accountability
and correct this recurring disgrace.
The federal civil suit by three female radiologists was
based on discrimination, a hostile, intimidating work
environment, and retaliation. It exposed the unprofessional
practice of Majid Khan, a radiologist who admitted that he did
not look at all images of every radiologic study for which he
gave interpretations. Even Dr. Khan's immediate supervisor and
co-defendant, Dr. Vipin Patel, admitted under oath that Dr.
Khan's conduct constituted ``intentional medical negligence''.
The motivation for this unprofessional conduct was money. A
radiologist's pay and performance evaluation was based on
productivity as defined by the Relative Value Units (RVU) that
the radiologist could produce. The most complex radiologic
studies generate the highest RVUs.
As other radiologists randomly discovered an unusually high
number of obvious, critical errors by Dr. Khan in patients who
were returning for followup imaging studies , Dr. Hatten
maintained a log of these errors. This log was sent up the
entire VA chain of oversight, which included Dr. Michael
Kussman, the VA Undersecretary for Health at the time. Of the
52 cases Dr. Hatten shared with VA leaders at every management
level, including the Office of Inspector General, there were,
for example, five lung cancers having become inoperable by the
time of their discovery.
VA officials have said that they performed due diligence by
having five separate examinations of Dr. Khan's professional
conduct. I provided the Office of Special Counsel a detailed
explanation of the contrived nature of each of these reviews,
administrative board of investigations (ABI), and Professional
Standards Boards (PSB) to produce a desired predetermined
outcome. To the unsuspecting observer these reviews appear to
be a bonafide effort to find the facts. This maze of deceit
allowed VA leaders to claim that no harm was done to patients,
the errors uncovered were within an acceptable statistical
norm, there was no responsibility for the VA to report these
adverse events to the patients or their surviving family, and
no indication to report Dr. Khan to his state licensing board
nor the National Practitioner Data Bank. Dr. Eric Undesser, the
chairman of the final AIB that exonerated Dr. Khan, admitted at
trial that he was well aware that a finding of negligence by
Dr. Khan would lead to numerous lawsuits against the VA.
I personally filed a professional conduct complaint about
Dr.Khan before the Mississippi Board of Medical Licensure
(MSBML). The mission of the MSBML is to protect all Mississippi
citizens, including those who are veterans. In response to my
complaint, the MSBML subpoenaed the Jackson VAMC for the 52
patient records as part of its investigation of Dr. Khan. The
VA has incredibly and irrationally refused to comply with this
subpoena, asserting the privacy rights of the patients.
Patients don't know they were injured since the VA has never
notified them, and they will never know if VA officials are
allowed to continue this coverup by hiding their misdeeds
behind privacy laws. The MSBML is a HIPPA exempted law
enforcement agency with every right to the information it is
seeking. This cover up is also in defiance of the VA's own
policy for complying with State Boards of Medical Licensure
(VHA Handbook 1100.18 Reporting and Responding to State
Licensing Boards).
The VA's response to my OSC complaint is nothing more than
a ``smoke and mirrors'' sleight of hand treatment of the facts.
``Intentional medical negligence''1 resulting in the death and
injury of patients is acceptable to the VA as long as the VA
can manipulate these patients in to a statistically acceptable
error rate, which the VA has assumed is present without
actually establishing it as fact. The VA response is an
extraordinary collection of useless contrived data presented as
definitive technical fact, euphemistic phraseology crafted to
misdirect the reader, and the omission of critical facts when
they contradict the VA's predetermined conclusions.
Fred Lucas, an army retiree, Vietnam veteran, an former VA
nurse wrote a guest column for the October 11, 2013 Clarion-
Ledger newspaper. Mr. Lucas quoted Mr. Joe Battle, Jackson VAMC
Director saying that the ``The VA considers the case closed''
referring to the radiology cases of injury never reported to
the patients or families. Dr. Randy Easterling, President of
the Mississippi State Board of Medical Licensure, in the April
3, 2013 Clarion-Ledger newspaper publicly criticized the
Jackson VAMC leadership's failure to cooperate with MSBML's
investigation of issues involving the Jackson VAMC.
For five years the position of Chief of Radiology at the
Jackson VAMC has remained vacant. The position has been openly
advertised on three different occasions. Dr. Margaret Hatten
and Dr. Brighid McIntire have served as acting chief of
radiology during the five years the chief's positions has been
vacant. Both of these ladies were plaintiffs in the Federal
trial, and though qualified for the chief's position, they have
never been entertained as serious candidates. This ``chronic
retaliation'' is for their role in exposing the leadership
culture of coverup of patient death and injury, lying as a
matter of routine, self dealing, and the unethical treatment of
patients, their families, and employees. The lesson that
speaking truth to power will abort your career advancement has
not been lost on other employees in the facility.
Before Kenneth Kizer, Undersecretary for Health during the
Clinton Presidency, modified the Senior Executive Service (SES)
compensation model to include pay for performance and generous
bonuses, the current leadership ills were unknown. When members
of the SES realized that there was essentially no oversight of
the pay for performance system by VACO, and that it was easy to
game the system, the least desirable elements of human came to
the fore. In my own clinic, waiting times for the next
available appointments and consults were reported to the VISN
with false data which were never shared with me, while I was
the ophthalmology section chief. Later, I discovered these
false data by chance. The medical center director had no
interest in hearing about or investigating the discrepancies in
the performance data. In fact, Kent Kirchner, the chief of
staff at the time, warned me away from pursuing any further
inquiry into the unrealistic performance reports about the eye
clinic.
I will conclude my remarks by suggesting to the committee
that not only should performance bonuses for SES leaders be
scrutinized but also should retention bonuses. SES leaders will
howl that good executives cannot be recruited without the
liberal use of these incentives. Awarding these compensation
incentives should use honesty and integrity as bench marks for
executives instead of the current performance measure system
which continues to be ripe for manipulation.
No longer should VA executives be evaluated solely by their
supervisors. This year the Chairman of the Joint Chiefs of
Staff announced that the military would use the 360 degree
evaluation technique for all high ranking officers. For years
corporations and medical schools have been using this
technique. The 360 degree technique allows peers and those
supervised to provide and assessment of personal character in
addition to their management qualities. The VA should adopt the
360 degree technique with evaluation instruments heavily
weighted to measure moral fitness, honesty, and integrity. The
VAs ``All Employee Survey'' doesn't do this.
Finally, some form of ``claw-back'' provision should be
developed for use by the agency or Congress against the
retirement benefits of SES employee who egregiously pursue
personal agendas through the auspices of the official
positions, or those who run out the clock into retirement or
transfer. Evasion of difficult management issues is just as
harmful as managing for personal gain. In both cases, these
executives defraud the government by willfully failing to
manage for the betterment of the veterans they have a fiduciary
responsibility to serve and the public who provides their
support.
The following narrative was submitted substantially in this
form in support of my complaint to the Office of Special
Counsel (OSC). This OSC was accepted for referral to the VA for
investigation and designated as OSC complaint DI-13-1713. This
narrative is not available on the OSC website for public
access, and is included here for the purpose of establishing a
context for understanding the full scope of VA leadership
failures.
ALLEGATIONS:
1. Violation of civil rights proven in Federal civil trial:
3:08cv00148TSL-FKB. This trial concluded in August of 2010 and
involved three VA physician plaintiffs vs VA management
officials at the G. V. ``Sonny'' Montgomery VA Medical Center
(GVSMVAMC) in the US District Court for the Southern District
of Mississippi, Jackson Division (Brighid McIntire, et.al. vs
James B. Peake, Secretary, Department of Veterans' Affairs)
Local VA defendants retained their positions without
prejudice. This case proved that hospital leadership actions
presented a clear and specific danger to the health and safety
of the veteran public that was NOT addressed after conclusion
of the lawsuit. Leadership officials would profit from their
decisions under pay for performance VA bonus administration. (I
will attach the trial transcript and relevant exhibits if this
website supports it).
2. Systematic ``gaming'' of monitored performance measures
to enhance professional advancement and increase pay for
performance salary bonuses.
A CHRONOLOGY OF GVSMVAMC's CHANGE IN LEADERSHIP CULTURE
FROM PATIENT CENTERED TO PERFORMANCE METRIC CENTERED
This is my personal recollection of events from my 30 years
with this VA hospital.
1. Kenneth Kizer, MD,MPH served as VA Undersecretary for
Health Affairs from 1994-1999. We began a program of health
care quality measures under him.
http://www.ftc.gov/ogc/healthcarehearings/docs/
030611kitzerjama020221.pdf
http://www.ucdmc.ucdavis.edu/iphi/kizer--bio--03302011
The following 1996 document is Kizer's actual plan, and
nearly all of it got implemented to some degree. Please note
that a) this is the start of the VISN system b) established
Primary Care as central healthcare focus [see Strategic
Objective #2, Reducing Cost, Actions 5, 12, & 13] c) Incentive
performance bonuses are established [ see Four Domains of
Value, Action 7 and Mission Goal II, objective 22]
http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf
2. Richard P. Miller was Center Director starting in 1996
or 1997 (the year Dr. Carter was shot and killed)
3. Miller retired around 2000. Robert Lynch was promoted to
director in a very odd way. He went from Chief of Staff
directly to director and bypassed acting as an Associate
Director first. In fact, he leaped over our Assoc. Director at
the time, a man named Bruce Triplett. A few months later, Lynch
applied for and got the job of Director of VISN 16. This
appeared to be a very inside job of self dealing since Lynch,
Miller, and the retiring VISN Director, Robert Higgins, had all
been the top leaders at the recently abolished ``Regional
Offices'' when Kizer set up the VISN system. We were not
surprised, since Lynch as Chief of Staff had removed the chief
of pathology, and selected his wife to be the new chief. To do
this he had to entirely reorganize the department of pathology
under the department of radiology and rename the whole thing
the department of Diagnostic Services. This conveniently got
around the prohibition of a manager supervising their family
member. The wife was supervised by the chief of radiology who
was supervised by Lynch. The radiology chief was Dr. Vipin
Patel, the same individual in the Federal lawsuit cited in
Allegations #1.
4. Dorothy White-Taylor, RN became Chief of Nursing in
2001. I cannot remember the date when Jonathan Perlin, MD from
VA Headquarters decided to make chiefs of nursing the official
at each medical center who would monitor the medical center
director's performance measures, but it was about that time. I
remember reading the email sent out over the old VISTA computer
system to all the hospitals announcing this arrangement. That
email should be indefinitely stored somewhere in the VA
Headquarters information technology system. I received this
email because I was both a VISN consultant for my specialty,
and I had been on a VISN construction committee.
5. Soon after Dr. Lynch took over as our hospital director,
an enormous emphasis was put on all sorts of performance
measurements. This was the result of pressure from Headquarters
and from the VISN director. It was natural for this to occur,
since better performance measures translated directly into
larger bonuses to the leadership (read Kizer's mission/ vision
statement again)
6. A not previously seen cadre of nurses with clipboards
were all over the place looking to find ways to make the
performance data better. It was all whip and no carrot. These
nurses who were not doing patient care, were nevertheless,
counted against the total number of nurses the hospital was
allowed to hire. They seemed to have a very protected role.
When they showed up to ask you questions about your performance
data, you were expected to drop everything and answer until
they were satisfied.
7. I personally witnessed activity designed to defeat so
called external audits of patient charts that were intended to
see how well our hospital implemented good care practices
compared to other VAs nationally and in VISN 16. This is what
would happen. The contracted external review entity would
notify the hospital a week before they would visit to review
some number of charts with a specific diagnosis of interest. I
don't recall how many charts would be pulled for any given
external audit. The room used was near my office and I would
pass by and see all the activity. Nurses or medical records
technicians were assigned to go over the pre-selected charts in
advance of the inspection. Charts not meeting criteria were
exchanged for charts that did. When the external reviewers
looked at this ``not so random sample'', our hospital got high
performance numbers. I specifically remember asking Myrtle
Kimble (now Tate) about this way of doing things. I had served
with Ms. Kimble on the Utilization Review Committee as its
chairman and knew her well. She told me that all the hospitals
were gaming the system and that we had to also in order to keep
a high performance rank among VA hospitals.
There was a nurse supervisor in charge of getting the
charts requested for audit ``cleaned up'' The nurse had been
given special authority to actually make appointments in the
computer so that patients whose charts were to be audited would
come to the hospital to correct their chart deficiency. For
example, if a check of foot pulses was not recorded in the
chart. This meant that patients came from long distances and
would be called to the hospital for their chart to be treated.
In addition to the risk of driving and direct expense to the
patient, travel pay for these appointments was also paid.
Medical records technicians and nurses told me that they
were paid overtime for any after hours and weekend chart work.
I never knew if data were fabricated if missing from the chart
or if patients could not be located. The entire system for
external audit subverted the external audit process. The
contracted external auditor was the Burton-Davis company, if my
memory is correct.
8. When the external reviews began to review specific
charts and not random ones, a new strategy went into place. As
I understood it, all of these data gathering/ verification
activities were run from the Chief of Nursing's office. In this
case, all the charts from a specific clinic had to be available
for review. Once the clinic had been identified (there were
never any surprise reviews; the hospital always got advance
notice of the date the reviewers would be there). Of course,
you could not substitute charts that met criteria in this
situation. You were forced to make an incomplete chart
complete. Once again this was done by paying nurses overtime on
the weekends and other times to call back to the hospital a
patient to have his records completed. I know of some cases
where patients were made to drive 60+ miles to have a blood
pressure taken and recorded or a foot exam documented. Minor
data points but an inconvenience to the patient and an added
travel pay and nurse overtime expense for the hospital. But our
performance numbers were excellent.
9. Some where in the mid-2000s all pretense at honest and
accurate gaming of the system seemed to go out the window. In
my own clinic the data self reported by our hospital through
the nursing service data collectors and analyzers bore no
resemblance to reality. I brought this up in an open Executive
Committee of the Medical Staff (now known as the Clinical
Executive Board) meeting with the Chief of Staff, Kent
Kirchner, who strongly suggested that I be content with my
clinic's performance doing so well. I don't remember if this
was shortly before or after Hurricane Katrina. After Katrina
most performance data changed to measuring services rendered to
hurricane displaced victims. At that point the pressure on
direct patient care providers relaxed somewhat for the next18
to 24 months.
10. Just before Richard Baltz was appointed as our medical
center director, my chief of surgery, Charles Clericuzio asked
me to prepare my own clinic's data for Mr. Baltz. Patient
waiting and appointment times were the primary issue and the
data and leadership expectations were divergent. Dr. Michael
Palmer and I prepared a presentation of data we could document.
Mr. Baltz was told we had the presentation prepared, but he
never asked for it. The clinics identified by Headquarters for
close monitoring and reporting were Cardiology, Urology,
Orthopedics, Ophthalmology, and one other that I can't recall.
These clinics had large patient panels and a high volume of new
requests for patient services. I think most of the full time
physicians strongly suspected that data generated by their
clinics were altered for improvement, since failure to
``massage'' the data would adversely affect the hospital's
reported performance measures outcomes. We almost never saw the
data as it was actually reported until long after the fact.
Once we realized that the leadership did not want to hear about
the data being suspect, we quit trying to push the issue.
11. My last director retired under a cloud of employee
complaints, but by this time the performance data factory was
pretty much running on autopilot. The leadership culture was
pretty well established and directed by the conflict of
interest between the Director, Chief Nurse, and the performance
measure chase which was directly tied to leadership
compensation levels.
12. The best documentation of the culture that pervaded the
hospital leadership comes, in my opinion, from the trial
transcript and exhibits of civil trial number : 3:08cv00148TSL-
FKB. This trial concluded in August of 2010 and involved three
VA physician plaintiffs vs VA management officials at the G. V.
``Sonny'' Montgomery VAMC in the US District Court for the
Southern District of Mississippi, Jackson Division (Brighid
McIntire, et.al. vs James B. Peake, Secretary, Department of
Veterans' Affairs)
This lawsuit documented direct injury (including deaths) to
veterans from performance data driven malpractice that was and
continues to be covered up by hospital officials. Use of
harassment, intimidation, and discrimination in order to
silence the plaintiffs reporting of patient safety and ethical
violations, was proven for the plaintiffs on all claims against
the VA. To this day, the responsible officials remain
unaccountable for their actions and are still employed by the
VA. VISN 16 and Headquarters officials with oversight
responsibility have remain untainted by their failure to act to
protect patients and employees. The physician who engaged in
substandard medical care for the sole purpose of inflating
performance measure data was giving a $5,000 special
contribution award and allowed to leave VA employment. His
``intentional medical negligence'' was never reported to the
Mississippi State Board of Medical Licensure. The more than
fifty patients adversely affected have never been notified
about what actually happened to them, except two who filed
malpractice claims.
In 2010 there was a physician-led survey of physician
attitudes and experiences with hospital leadership. The results
were sent to the Secretary of the VA, the Mississippi
Congressional delegation, VISN 16 Network Director, and others.
I believe it was dismissed as the product of disgruntled
employees. The result was that the failure to assure patient
safety and the abuse of authority by VA leaders were ignored.
13. The absence of trust in VA leadership and low employee
morale at the G. V. ``Sonny'' Montgomery VAMC is the result of
the failure by numerous internal and external entities to
conduct open investigations of allegations made to them. These
so called investigations did not put witnesses under oath and
did not generate a report or transcript. These include VA
Headquarters, VAOIG, Office of Special Counsel (when Scott
Bloch was the Special Counsel), The Joint Commission, and the
Department of Labor. Officials of most of these entities were
given information about abuse of authority and ethical lapses
that led to the deaths of patients. It also demonstrates the
inherent information advantage that the hospital leadership
leveraged to undermine, dismiss, or deflect allegations of
misconduct, mismanagement, and abuse of authority against them.
It also demonstrates the inability of agencies with oversight
responsibility to see and understand a pattern of mismanagement
and abuse of authority over time by the same management
officials. Each allegation appears to have been processed as
solitary event with no appreciation for the larger picture of
interconnected events in the management of the hospital.
14. Unrelated to the provision of direct medical care, but
demonstrative of abuse of authority is the harassment and
retaliation against two employees with military obligations.
Major General Cathy Lutz and Colonel Dale Hetrick were audited
to produce deployment orders many years after their deployments
to Iraq and other conflict zones. This audit was proximate to
their objections to the then hospital director and initially
involved no other employees with prior military obligations.
Although Human Resources (HR) was required to obtain their
orders prior to deployment and maintain them in their personnel
records, Colonel Hetrick and General Lutz were told that HR
could not locate copies of their orders. The threat of large
repayments of undocumented leave for military deployment unless
the old orders were presented was used against them. The audit
took place after Colonel Hetrick's retirement from the Marine
Corp. reserve and encompassed the years 2004 through 2010. He
was asked to repay $19,504.12 to the VA; a sum he did not owe.
Colonel Hetrick chose demotion from his position as AA to the
director, though he produced copies of his old orders, and
General Lutz chose retirement instead of pursuing the matter in
the courts.
15. The fault that makes all of this possible lies in the
conflict of interest that is inherent in the Senior Executive
Service retention and performance bonus compensation system.
This money distorts the ethical boundaries of VA leaders and is
directly tied to performance measure metrics as currently
structured and administered within the VA. The absence of
objective accounting principles to detect data corruption and
manipulation are an incentive to ``game'' the performance data
system as it currently stands. It is an open invitation for
abuse. When successful lawsuits against the agency do not lead
to reforms, even the leadership at the local hospital level,
having no expectation of being held accountable, simply view
such events as a nuisance and the cost of doing business. The
cost to any individual member of VA leadership is nothing since
the taxpayer bears court costs and judgements. Finally, without
any ``clawback'' provisions in law, officials with oversight
responsibilities near the end of their VA employment or current
job have a strong incentive to ignore allegations of wrongdoing
and simply run out the clock.
16. For the purpose of brevity the remainder of my written
testimony consists of the following cited items:
a. Transcript, exhibits, jury verdict, and index to the
transcript of Federal civil trial number: 3:08cv00148TSL-FKB,
UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF MISSISSIPPI
JACKSON DIVISION;
BRIGHID MCINTIRE, ET AL. PLAINTIFFS
VS. JAMES B. PEAKE,SECRETARY,
DEPARTMENT OF VETERANS' AFFAIRS
b. VA Organizational Code of Ethics
c. Office of Special Counsel Complaint DI- 13-1713 with
whistleblower comments: http://www.osc.gov/FY%202013%20A.html
d. http://commdocs.house.gov/committees/vets/hvr031199.000/
hvr031199--0f.htm
!999 O & I subcommittee hearing on VA Whistleblower
Retaliation
e. VHA Handbook 1004.08 Disclosure of Adverse Events to
Patients
f. Talking Points for Disclosure of Adverse Events to
Patients
g. August 26, 2010 letter to Mark R. Chassin, President of
the Joint Commission concerning understaffing in the Emergency
Department, Radiology, and Primary Care
h. April 3, 2013 Clarion-Ledger, Some Nurses Lacked Papers,
by Jerry Mitchell
i. August 22, 2011 Clarion-Ledger, Bill Minor Letter to the
Editor
j. January 5, 2011 Memorandum from VISN 16 Network Director
to Jackson VAMC Director. MICU Staffing and Emergency
Department coverage
k. September 24, 2010 Executive Leadership Council South
Central VA Health Care Network Video Conference minutes.
l. February 25, 2011 Executive Leadership Council South
Central VA Health Care Network Video Conference minutes.
m. January 7, 2011 Email/ memo from Charles Jenkins
regarding MICU understaffing and no leadership accountability.
n. May 5, 2011 Clarion- Ledger, ``Death: Circumstances of
case 'ghastly', attorney for family says'' by Jerry Mitchell
o. PL 108-445 Department of Veterans Affairs Health Care
Personnel Enhancement Act of 2004 (Physician Pay Bill)
p. Sentinel Events definition and reporting, The Joint
Commission: http://www.jointcommission.org/assets/1/6/CAMH--
2012--Update2--24--SE.pdf
q. April 13, 2013, New York Times: ``Conduct at Issue as
Military Officers Face a New Review'' by Thom Shanker
r. Department of Veterans Affairs, Veterans Health
Administration, VHA Handbook 1100. 18: Reporting and Responding
to State Licensing Boards
Federal trial transcript vol 3, p 190, line 21 through p
191, line 7
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Mr. Coffman. General Hearon, you have two and a half
minutes to deliver your remarks, please.
STATEMENT OF ERIK HEARON
Major General *Hearon.* My name is Erik Hearon, a CPA from
Mississippi, and I also served 40 years in the air force and
the Mississippi Air National Guard.
I am here today with but one purpose in mind, to praise and
thank veterans for giving us the opportunity to hold such a
hearing.
The issues are fundamental and the solutions are apparent,
but they have eluded the VA management. Quality healthcare is a
benefit earned by our veterans. It is not free medical care.
Legislation protects it.
The two opening statements by the chairman and the ranking
minority member were excellent. In fact, they said much of what
I had in my remarks which are focused on the management side of
the house since the medical side has been very well covered.
I had the honor of knowing Sonny Montgomery. His portrait
is on this wall. I actually intentionally brought the hat for
the dedication of the C17 to Sonny. His memory means a lot to
me and to the veterans that are supposed to get quality care up
there.
The remarks in addition to what you all said which was
excellent, I would like for you to consider that a few months
ago it was stated that the veterans' benefits processing would
be privatized if they were not fixed by 2015.
I ask that you consider the comments in my written remarks
and the estimated calculations from my CPA side of the brain
that says we could save about $4.6 billion per year by issuing
insurance policies to the veterans and letting them get their
care much easier at private clinics than by traveling in some
cases great distances to Jackson.
In May of 2011, there was a hearing held in this very room
where a lot of promises were made by the VA, and I have seen no
evidence that they were fulfilled. A quote from that is in my
written remarks.
The Office of Special Counsel has been an integral part of
getting information from and about the VA in Jackson and
elsewhere. They are painfully aware of that operation.
I talked one week ago today with a veteran who had been
misdiagnosed or not diagnosed at all, allowed only to see nurse
practitioners, no physicians, for two years. He was informed
that he had cancer earlier this year, had his entire stomach
removed in September, and only then was he allowed to see a
doctor who refused to give him leave from work. He was a VA
employee as well. He was terminated and is short one month pay.
And it has just been an absolute disaster.
The State of Iowa does not require collaboration. Some of
our nurse practitioners have gone there for licensing in order
to avoid the supervision that the patients so desperately
deserve.
I am over time. I apologize. And I very much appreciate the
opportunity to be here with you all. Look forward to any
questions later.
[THE PREPARED STATEMENT OF ERIK HEARON]
``Correcting `Kerfuffles' - Analyzing Prohibited Practices
and Preventable Patient Deaths at Jackson VAMC''
For the O&I hearing on November 13, 2013 at 10:00; 334
Cannon House Office Building, Washington, DC
Written Comments for the Record by Erik Hearon, CPA and Maj
Gen (USAF) (Ret.)
Honor Veterans with a Much Improved VA Health
Administration and Central Office
Committee members and staff, thank you for your commitment
to ensuring proper care for and treatment of our precious
veterans. This hearing focuses on the VA Medical Center in
Jackson, MS and is one in a long line of hearings you have held
to focus on issues at many VA Medical Centers. This does not
excuse Jackson. Instead, the pattern of ongoing but uncorrected
errors lasting a decade or more proves many critical points
about the systemic VA failures of leadership nationwide.
The dictionary defines kerfuffle as fuss, commotion, to
disorder, confuse - all perfect descriptions for some aspects
of the Jackson and nationwide VA operations.
In addition to these written comments, I have provided the
Subcommittee with two copies of a videodisk of the April 3,
2013 ``town hall meeting'' in Jackson.
Panel 1 represents over two hundred people in the Jackson,
MS area who are very interested in the VA providing the best
professional, timely and organized health care to our veterans.
Our group is composed of veterans, past and current employees
of the VA and concerned citizens. We do not have an official
name or a budget. One thing we do have is a strong ongoing
commitment to exposing areas for improvement in Jackson and
nationally until the issues are fixed.
We thank and support all VA employees who provide
professional, caring health care to our veterans. Those who
consistently follow the I CARE core values of Integrity,
Commitment, Advocacy, Respect and Excellence should be emulated
by the others. We wish there was no need for negative
discussion, media coverage or Congressional inquiries. We also
thank the Office of Special Counsel and every veterans'
organization, each investing significant time and resources
into improving the VA's management and health care.
One of the members testifying today in the other panel gave
me the title ``Chief Instigator.'' I wish that our group's work
was no longer needed but there is no sign that we have
succeeded in our pursuit for improved management. Transfers to
the VISN (Veterans Integrated Service Network) office and to
another VISN have not improved health for veterans overall.
During my forty years of military service I heard many
stories about deficiencies in the operation of the Jackson VA
Medical Center, which is named for G. V. ``Sonny'' Montgomery.
Sonny served in World War II, earned the Bronze Star with Valor
and the Combat Infantry Badge, served in the Mississippi House
for ten years and served in the US House from 1967 to 1997,
including chairing your committee from 1985 to 1997. The
Montgomery GI Bill is named for Sonny, as are a C-17 cargo
aircraft, the conference room at the VA's Central Office and
many other VA and non-VA facilities. Sonny also received the
Presidential Medal of Freedom.
Whenever Sonny was asked ``Are you red or blue?'' his
consistent answer was ``I am red, white and blue.'' Supporting
issues to protect national security and Veterans were at the
top of his priorities. These issues have normally enjoyed broad
bipartisan support and we trust that this pattern will
continue. We are sure that the current committee has the same
dedication to veterans as did Sonny.
We celebrated Veterans Day two days ago, honoring and
thanking the millions of men and women, as well as their
families, of all races and faiths who have defended our many
freedoms. Their dedication and sacrifice have always protected
our freedoms and us for centuries. Chairman Coffman's service
in the Army and Marine Corps and during the Gulf War and the
Iraq War are extremely laudable. We also thank Rep. Tim Walz
for his twenty-four years of military service.
We must remember President Lincoln's commitment in his
second inaugural address ``to care for him who shall have borne
the battle and for his widow and his orphan.'' The Department
of Veterans Affairs has been responsible for fulfilling
President Lincoln's commitment. I believe that the spirit with
which Sonny served Veterans has been displayed in several
management actions of the current VA administration.
The VA has more than 1,700 facilities, employs over 200,000
people and cares for over 6.3 million Veterans each year. The
VA's Health Administration (VHA) expenditures are over $53.4
billion or about $8,500 per patient per year on average.
A House Veterans' Affairs Committee (HVAC) hearing in April
2013 included a commitment by a Congressman to the VA that he
would introduce legislation to privatize the benefits process
if the claims backlog has not been resolved by 2015. I ask that
a similar challenge and commitment should be made now if some
significant aspects of health care aren't dramatically
improved. The replacement to the VHA should provide the same
level of coverage and care through insurance from the private
sector and would, I estimate, save at least $4.6 billion
annually. The calculations for my estimate for this are at the
end of these comments but the primary reason for the suggestion
to change to insurance would be to provide better, safer and
more appropriately monitored care.
While very many of the VAMCs' physicians and other health
care professionals provide excellent care to the patients,
management has a much more mixed record. The VA management's
failures result in cancelled and delayed appointments, interim
and occupants of what should be permanent employees, reduced
continuity of care, failure to enforce standards due to the
shortages and other issues leading to decreased patient safety
and care.
The HVAC has been diligent in pursuing improvements at the
VA, holding a hearing in Pittsburgh, PA on September 9 that
focused on lack of accountability, questionable bonuses,
preventable deaths and patient safety issues. Five VAMCs were
in the spotlight: Pittsburgh, Buffalo, Atlanta, Jackson and
Dallas.
Dr. Petzel was the lead representative in Pittsburgh from
the VA. He has been the Under Secretary for Health for the VA
since February 18, 2010 but is ``retiring'' some time in 2014.
I attended the Pittsburgh hearing and am convinced that the
U.S. Representatives conducting the hearing were skeptical
initially because of prior events but seemed insulted by some
of the VA's responses that day and many failures to respond to
the Committee before.
After the Pittsburgh hearing, an incredibly misleading and
incomplete press release was published on behalf of Robert A.
Petzel, MD, by the VA Central Office in Washington. The press
release was a blurred snapshot with so much ``photo-shopping''
that the actual event was hard to visualize.
The most significant omission or kerfuffle in the press
release is that virtually every medical treatment error relates
to ongoing poor management over many years but no errors were
mentioned. This includes management in some VAMCs, networks (a
group of about ten VAMCs) and the VA's Central Office, from
chiefs in hospital departments to the Secretary.
An ongoing lack of accountability by VA management
personnel was one focus of the hearing. The Pittsburgh VA had
five patients die and others sickened (all veterans) recently
from Legionella, after multiple warnings about improper
maintenance of the water system, going back to 2010. A simple
fix had been recommended and ignored, resulting in the
unnecessary deaths.
The Pittsburgh VAMC had a world-class research lab to study
Legionella but it was closed several years ago by the
hospital's director, Michael Moreland, and the samples were
destroyed. However, Mr. Moreland was promoted to director over
ten VAMCs as well as forty-three outpatient clinics and awarded
a Presidential award for a ``lifetime of service'', based on
the recommendation of Dr. Petzel. The award included a $63,000
bonus. The HVAC hearing focused on this as well. Dr. Petzel
said ``yes'' when asked whether or not he would still nominate
Mr. Moreland knowing all of the events leading up to the
hearing and the deaths. Mr. Moreland's retirement was announced
October 4 and his replacement was announced October 24,
effective November 2. He was asked to return the $63,000 award
during the HVAC hearing in Pittsburgh. The VA said that they do
not have a mechanism to ``claw back'' bonuses. How do the
circumstances around Mr. Moreland's promotion, bonus, etc.
exemplify any standard of integrity, transparency, leadership,
care, etc.?
Bonuses to ``leaders'' at facilities and networks with
serious and well-known problems were another focus of the
hearing but were not mentioned in the VA's press release. The
criteria and calculations for bonuses are closely guarded
secrets but the HVAC and some in the media have worked to crack
the wall of secrecy. Some people directly or indirectly in
charge of VAMCs which had, and often still have, significant
medical errors received bonuses anyway as investigated by your
committee.
Bonuses of over $408 million in a recent fiscal year show
that bonuses are treated as an entitlement to some rather than
for service over and above normal. If an employee cannot
consistently follow the I CARE core values, they should be
reprimanded, receive no bonus for that year and their appraisal
should reflect this. An investigative story titled ``Death and
Dishonor: Crisis at the VA'' aired two days ago on CNBC and
highlighted the bonus issue in Jackson, as have other media
reports.
Several families testified about suicides and other deaths
resulting from VA errors and management issues, including
under-staffing. Dr. Petzel's attempt at apologizing to the
families was enough to make about 90% of the audience groan.
The VA's culture of tolerating a certain level of
unnecessary patient deaths and injury should never have existed
and must be immediately stopped, with disciplinary action for
those who accepted it. Suicides and other unnecessary deaths
have not received a proper and forceful response.
A culture of not removing problem employees exists in
Jackson. Transfers from a VAMC to another VAMC or network have
been considered as corrective but keep them on the VA payroll
without taking real action.
The Office of Special Counsel (OSC) is an independent
federal investigative and prosecutorial agency. The OSC has
received proportionately more complaints about the VA than any
other US Government agency. Everyone who wants better
performance at the VA at all levels appreciates the OSC's
diligent work to make this happen. If the VA would pursue
corrective actions on substantiated complaints we might not
need this hearing. Secretary Shinseki has signed many reports
to the OSC, including about Jackson, but no leadership
personnel have received noticeable adverse actions.
Considering the reports to the OSC and the many reports of
needed corrections from the VA's Office of the Inspector
General, the number of repetitive problems should have been a
huge wakeup call long ago.
Many issues have also been brought to the VA's attention by
House and Senate Veterans' Affairs Committees. It seems like an
extremely sad and expensive whac-a-mole game wherein the same
problem occurs in a new location when the VA says it has
resolved the same issue in recent but different locations.
Problems have existed in some VAMCs about improper narcotic
prescriptions. The management of the VAMC in Jackson, MS has
fought with the MS Boards of Medical Licensure and Nursing, as
well as the DEA, about some Nurse Practitioners operating
beyond their license. Some nurse practitioners at Jackson have
even obtained a license from Iowa, although Mississippi has
been their source before, because Iowa does not require
collaboration or supervision of them by a physician. Ultimately
patient health and safety are at risk as illustrated by a
tragic situation described below.
Allowing employees who have been previously licensed in
their state of residence and the VA facility at which they work
to change to another state for licensing should not be allowed.
It allows people to seek the path of least resistance
(demonstrated professional knowledge). If they can not pass the
test in their home state, move to Iowa or a similar state of
lax licensing requirements. Patient safety is compromised now.
Patients around the country rely on state Boards of Health,
Medical Licensure and Nursing as a critical link in assuring
that only competent medical professionals are allowed to
practice. Mississippi is no different. However, the ``federal
supremacy'' concept precludes those state agencies from
performing their normal monitoring duties to protect patient
safety. The agencies cannot improve the attitude of a small
percentage of those in Jackson who apparently feel that the
patients are an inconvenience but they can more diligently make
normal inquiries as well as investigate complaints.
The legal concept of ``federal supremacy'' adversely
impacts the health of VA patients. The state agencies already
perform inspections in almost all hospitals, nursing homes,
etc. to ensure the quality of patient care. They have been
stiff-armed in Jackson and federal facilities throughout the
country. The ``federal supremacy'' concept should be abandoned
immediately for the entire VA system.
Effective initial and continuing training for VA
supervisors and ``leaders'' does not exist. If the training
were effective, the same or very similar problems would not
keep appearing. Most VAMCs and networks are run safely and
effectively but others do not have management with a sense of
dedication, service and integrity. When the OSC investigated
errors in prescribing narcotics and the VA promised they had
changed, within one week the Jackson VA was again telling
physicians to prescribe narcotics for patients they had not
examined.
Many critical management practices must be corrected. The
VA claims to follow core values as described in their I CARE
posters: Integrity, Commitment, Advocacy, Respect and
Excellence. If the VA lived by the I CARE values, job openings
for medical professionals would be few and easily filled,
``leadership'' positions would be filled by permanent employees
instead of having so many ``acting service chiefs'' (the
Jackson VAMC has spent a year with 15-17 acting chiefs),
continuity of care and management would be greatly improved
with resulting increases in quality of care and employee
morale, employee appraisals would be accurate, inspections
would be routine, media and Congressional inquiries would not
be feared, and VA press releases would be much more truthful.
Your full Committee held a hearing on May 3, 2011 in this
same room. The subject was ``Sacred Obligation: Restoring
Veteran Trust and Patient Safety'', a laudable and reasonable
expectation. Chairman Jeff Miller's remarks included ``After
these incidents [of serious patient safety violations] the VA
assured Congress and the country that it was aggressively
addressing patient safety issues and never again would a
veteran's trust be compromised by lapses in quality care at a
VA medical facility and, yet, each patient safety incident has
seemingly led the way for the next lessons learned and the
unacceptable and inexcusable revelation that the patient safety
culture in VA is fractured and accountability and leadership at
the helm are lacking. The time for talk is over.'' (page 4)
Legionella in Pittsburgh and a significant turnover and lack of
physicians, at least in Jackson, are clear signs that the VA's
assurances on May 3, 2011 have not been fulfilled. The subject
for that hearing should have been easily understood and
attained by the VA but it has not been in too many situations.
The culture that has grown over the last decade or more in
Jackson has not improved the trust of veterans. Mr. Joe Battle,
the center director, has been in Jackson for one year and ten
months. In my view, Mr. Battle is a fine person and has tried
hard to improve health care but has been hampered and
constrained by the apparent lack of information and support by
his staff, VISN 16 and the VA Central Office.
At the urging of U.S. Senators Cochran and Wicker from
Mississippi, a ``town hall'' meeting was held in Jackson April
3, 2013. Robert Petzel, MD, Under Secretary of Health for the
VA, was the key speaker, accompanied by Gregg Parker, MD, Ms.
Rica Lewis-Payton from VISN16 and others. An opportunity to
restore communications and trust between the VA and over 200
veterans in attendance was completely wasted and actually
fueled the frustration. The third relatively recent article in
the New York Times about the Jackson VA's challenges was in the
next day's issue and was about one-half page with a photograph.
The ratio of physicians and nurse practitioners in primary
care in Jackson has been skewed for years. The ratio has been
three nurse practitioners (NPs) per physician but is now said
by the VA to be approaching two to one. The 3:1 ratio evolving
from the direct efforts of a former Chief of Nursing Services
who resisted the hiring of physicians. She was arrested on
narcotic charges May 23, 2012 and returned to work about
thirteen (13) months later after criminal charges were dropped.
She received her pay of about $170,000 annually throughout that
absence. The New York Times reported in a September 9, 2013
article that she ``received $61,250 in performance bonuses
between 2003 and 2011''. I personally had a DEA agent tell me
that they would not be able to pursue the case against her
``due to political pressure''. She has been assigned to VISN16.
Another factor in some lapses in quality care is that the
professional judgment and medical orders of some physicians
were overridden by a nurse practitioner. While the large
majority of NPs in Jackson provide caring and professional
care, some appear to feel that they are qualified to make
better decisions than the physicians. When this situation
arises and particularly when it is allowed to stand, the insult
to physicians is dramatic and well known among the staff.
Just this past Wednesday, one week ago today, I was told
about and interviewed a veteran of over twenty years who also
happened to be an employee of the Jackson VAMC. He and his wife
told me that he had been seen for almost two years only by
nurse practitioners and could not see a physician. They went
back for his appointments each three to four months complaining
of increasing levels of pain. Each time he was given medicine
just above the level of aspirin and given another appointment.
They said the VA drew his blood for a routine test on each
visit but never ran a CA-125 test to check for cancer, although
a CT scan had disclosed ``something''. He finally and totally
lost faith in the VA's health care and obtained non-VA medical
care, which discovered this past April that he had
adenocarcinoma in the stomach. His private oncologist wrote him
an excuse to miss work indefinitely while he received
chemotherapy but the VA Human Resources department would only
accept the document for six months. At the end of that time and
while still receiving chemotherapy he had to argue with a
physician in primary care and she finally extended the excused
absence for three days, yes, three days. The physician also all
but told him he was being a slacker, based on her view of other
patients' actions. His entire stomach was removed about two
months ago. Some of his small intestines were made into a
stomach and he continues chemotherapy. He missed an entire
month's pay, has not received it yet, is out of the VA pay
system, receives Social Security Disability and $230 monthly
from the VA. He also lost about $5,000 out-of-pocket on
insurance deductibles since he could not get his earned but
insufficient care at the VA for his illness. He has not
received an institutional disclosure from the VA, not to
mention an apology for misdiagnosis. He has a wife and six
children. The spirits of the parents are much better due to
their faith than I expected but their upcoming financial and
health situations are of great concern. In my view, he should
immediately receive a personal apology from the primary care
physician, his full pay for the month or so gap created when
paperwork was not properly handled, reimbursement of the full
amount of his insurance deductibles and an institutional
disclosure to help him understand his legal alternatives with
the VA. He is the second veteran I have talked to in the last
five months with a very similar story.
The horrific situation described above comes after the
well-publicized April 1, 2011 death of a veteran within a very
few hours of surgery. Johnnie Lee bled to death in recovery
because no one checked on him for hours. Before Mr. Lee's
death, the FDA issued warnings in 2009 and February 2011. The
medical procedure required checking the patient about every
fifteen minutes. The VA claims that The Joint Commission (also
known as JACO) investigated the case of Mr. Lee's death and
decided that nothing was done wrong. In my mind, the quality of
the investigation by JACO in this case was substandard and
disqualifies JACO inspections as qualifying as any comfort
about the quality of care at Jackson and nationwide.
At the Jackson VAMC, there are no orthopedic surgeons or
podiatrists. It is obvious that those specialties and many
others are needed for the patient population. Those services
have been contracted to outside facilities. However, several if
not all of the best local orthopedic practices have
discontinued accepting referrals from the VA due to non-payment
from the VA for extended periods. After relying on outside
practices and being unable to staff the specialty themselves,
the VA's Central Fiscal Office should be examined and
reprimanded, if appropriate, with firings due to the impact on
patient care of their delay in paying legitimate bills. The
slow payments to vendors also came up in the April 3, 2013
``town hall'' meeting.
There should absolutely not be funds for bonuses to VA
``leadership'' if the health care providers cannot be paid on
time.
The terror faced by some veterans after medical errors has
been exacerbated by the VA and US Attorneys. A World War II
veteran in Jackson who drove other veterans to the hospital was
blinded in both eyes after an undiluted solution was put in
both eyes for cataract surgery. The covering to both eyes
boiled away. His whole life turned upside down. Very limited
help was offered by the VA. The VA and US attorneys fought him
tooth and nail in court and lost. If his situation could have
been made worse, the VA and US attorneys found a way to do so
in this and other cases.
Accountability, highlighted at the Pittsburgh hearing as a
critical factor, has been partially shown in two instances. A
physician who was Chief of Staff in Jackson instructed
physicians to prescribe narcotics to patients who had not been
examined by that physician, which risked the medical license of
physicians who followed his instructions. He was ultimately
removed from his ``leadership'' position where he saw very few
if any patients but he remains in the Jackson VA medical center
as a physician, creating ``kerfuffle'' or confusion among other
employees as to his true role. Additionally, the Chief of
Primary Care received enough encouragement to get him out of
the Jackson VA but he transferred to a VA in Mountain Home, TN,
in another VISN.
The VA website states that they are ``the nation's largest
integrated health care system . . . ''. Some financial
institutions were said to be too large to fail. I suggest that
it is past time to consider whether the VA is too big to
succeed.
What is the solution? Any solution must include the
immediate retirement or termination of all ``leaders'' who knew
or should have known of the practices which led to patient
deaths or serious injury or who condoned lapses of ethics and
integrity. The changes must be transparent and decisive to
restore trust among the Veterans. Actions by people in
``leadership'' positions, as well as their lack of actions,
send messages to employees and the veterans. The message so far
has often been ``no matter what you do or how much you ignore
the I CARE core values, we will not fire you.'' To paraphrase
General Colin Powell's first rule of leadership, ``Being
responsible sometimes means making some people very mad.''
The solution to ongoing VA problems must also include the
retirement of Secretary Eric Shinseki. While he had a
distinguished military career, Secretary Shinseki has failed to
acknowledge and correct leadership deficiencies or serious and
well-known problems affecting many Veterans.
Secretary Shinseki has signed so many reports to the
Congress and OSC acknowledging deficiencies that he has no
plausible deniability about knowing of serious problems in
VISN16, Jackson and elsewhere. Leadership starts at the top and
he is directly and personally responsible for his failure to
lead the VA or to hold his staff accountable. The responsible
action is for Secretary Shinseki to resign, along with Dr.
Petzel, Mr. Moreland and others. Those willing and able to
perform for the veterans should be encouraged and the others
should leave the VA. Only a clean house, with the windows wide
open, will restore the lost trust of the Veterans and show that
the VA truly cares.
Again we thank the Oversight and Investigations
Subcommittee, the full Committee and your staffs for continuing
to focus the VA on accountability, responsibility,
transparency, transformation and fully pursuing their core
values of I CARE. Thank you for the Accountability Watch
featured on your website. We also thank the Office of Special
Counsel and the media in Jackson and around the country for
covering the shortcomings, as well as the successes, of the VA.
We especially thank those current and former VA employees
who care for our veterans appropriately and who have shared
information to improve the medical care.
We look forward to continuing work with the Committee in
the future to support your critical oversight. Thank you and
God Bless America.
Veterans Health Administration (VHA)
Comparison of Providing Insurance v. VHA Costs; Estimated
52 Medical Centers, 817 Community-Based Outpatient Clinics
Money spent in Veterans Health Administration, FY12, per VA
Performance and Accountability Report, unaudited ($ in
millions)
Budgetary; Part IV, page 4; Note (1)
Personnel compensation and benefits
Other contractual services
Supplies and materials
Land and structures
Equipment
Rent, communications and utilities
Grants, subsidies and contributions
Other
Less VA Community Living Centers / Nursing Home; Note (2)
Plus FY13 VHA construction request; Note (3)
Total
Note: FY13 discretionary funding for Medical Care $55,672
million
$417 million for General Administration and $1,271 million
for
construction and grants; Note (4)
2013 premium example; standard option for veteran only;
includes
monthly gov't + employee premiums; Note (5)
times number of months to annualize
premium per patient per year; estimated
times number of unique patients in VA system; FY12
estimate;
Note (6); in millions
Estimated premiums for veterans only; in millions $
Estimated additional amount for covered family--10%
Total estimated premiums (in millions)
Estimated savings to close VHA portion of VA (millions per
year)
Notes:
(1) www.va.gov/budget/docs/report/PartIV/2012-VAPAR--Part--
IV.pdf
(2) VA 2013 Congressional Submission; page 1A-5; FY12
estimated
(3) VA FY13 Budget Request, Vol IV, page 1-1
(4) www.va.gov/budget/docs/summary/Fy2013--Fast--Facts--
VAs----
Budget--Highlights.pdf
(5) as an example, 2013 Blue Cross and Blue Shield Service
Benefit Plan; non-Postal premium; page 150 of printed brochure;
www.fepblue.org
(6) www.va.gov/budget/docs/report/PartI/2012-VAPAR--Part--
I.pdf; page I-31
$ 27,529
11,580
8,784
3,231
2,058
1,869
1,300
1,040
(4,250)
1,024
54,165
600
12
7,200
6.2547
45,034
4,503
49,537
$ 4,628
Some articles (links where available) to some media stories
about Jackson's VA and the VA system:
Title
Author; source; link
Death at VA hospital probed; Employee found dead in room
after routine leg surgery
Jerry Mitchell; Clarion Ledger; published May 8, 2011
Jackson VA Hospital official (Dorothy White-Taylor) charged
with drug fraud
Clarion Ledger; published May 24, 2012
Rep. Bennie Thompson asks probe of VA staffing, patient
care
Clarion Ledger; published June 13, 2012
Documents link deaths to improper VA staffing
Jerry Mitchell; Clarion Ledger; published August 25, 2012
Narcotic scripts focus of VA probe
Jerry Mitchell; Clarion Ledger; published August 25, 2012
Congressional Investigation of Jackson VA in order
Charles ``Todd'' Sherwood; op-ed in Clarion Ledger;
published September 12, 2012
Federal probe: VA hospital in Jackson subject of scathing
report
Robert Burns (AP); Clarion Ledger; published March 20,
2013; clarionledger.com/viewart/20130320/NEWS01/303200028/
Federal-probe-VA-hospital-Jackson-subject-scathing-report
Town hall opportunity to discuss veteran care at Jackson VA
Senator Roger Wicker; op-ed in Clarion Ledger; published
March 24, 2013
Questions welcome at VA town hall meeting
Jerry Mitchell; Clarion Ledger; published March 30, 2013;
clarionledger.com/apps/pbcs.dll/article?AID=2013303300025
VA's appalling failure in MS are not recent problems
Sid Salter; op-ed; Clarion Ledger; published March 31,
2013; clarionledger.com/apps/ pbcs.dll/article?AID= 2013303
310030
Some VA nurses went out of state for needed certification;
certification from Iowa seen as way to skirt MS Boards
Jerry Mitchell; Clarion Ledger; published April 3, 2013;
clarionledger.com/apps/ pbcs.dll/article?AID=2013304030012
Some vets frustrated by one-sided format at VA town hall
meeting; Officials say hospital one of best in nation
Jerry Mitchell; Clarion Ledger; published April 4, 2013;
clarionledger.com/apps/ pbcs.dll/article?AID=2013304040047
Meeting didn't give veterans chance to speak on issues
Clarion Ledger editorial; published April 5, 2013;
clarionledger.com/article/20130405/ OPINION01/304050015/
Meeting-didn-t-give-veterans-chance-speak-issues
VA can't get worse, must get better
Bob Slater, Madison, MS letter to the editor; Clarion
Ledger; published September 19, 2013; clarionledger.com/apps/
pbcs.dll/
article?AID=/201309201635/OPINION02/ 309200320
Counsel: VA deficient in care, responding to problems
Jerry Mitchell; Clarion Ledger; published September 22,
2013
Veterans no longer trust VA hospital for care; mentions
numerous names
Fred Lucas (veteran); op-ed; Clarion Ledger; published
October 12, 2013; clarionledger.com/apps/pbcs.dll/
article?AID=2013310120035
A Pattern of Problems at a Hospital for Veterans
James Dao; New York Times; published March 19, 2013;
nytimes.com/2013/03/ 19/us/whistle-blower-complaints-at-
veterans-hospital-in-mississippi.html?emc= eta1&--r=0
Veterans Affairs Officials Offer Reassurance About Troubled
Hospital
James Dao; New York Times; published April 4, 2013;
nytimes.com/2013/04/04/us /veterans-affairs-officials-offer-
reassurance-about-troubled-hospital.html?--r=0
V.A. Inquiry Finds Inadequate Staffing of Doctors at
Mississippi Hospital; re accusations by Dr. Phyllis Hollenbeck
James Dao; New York Times; published September 9, 2013;
nytimes.com/2013/09/09/ us/inquiry-finds-inadequate-staffing-
at-mississippi-veterans-hospital.html?--r=0
Death and Dishonor: Crisis at the VA
Dina Gusovsky; CNBC documentary; cnbc.com/id/10001293?--
source=vty%7C investigationsinc%7C&par=vty
20 Buffalo VA patients test positive for hepatitis
Jerry Zremski; Buffalo News; printed May 9, 2013;
buffalonews.com/apps/pbcs.dll/artic le?AID=/20130509/
CITYANDREGION/ 130509231
Mr. Coffman. Thank you, General.
Mr. Jenkins, you are now recognized for five minutes.
STATEMENT OF CHARLES JENKINS
Mr. Jenkins. Thank you, Chairman Coffman, Ranking Member
Kirkpatrick, and committee Members. I appreciate the
opportunity to be here.
My name is Charles W. Jenkins. I am the elected president
for the American Federation of Government Employees at the G.V.
Sonny Montgomery VA Medical Center.
I represent over 900 employees at the medical center which
includes some nursing assistants, licensed practical nurses,
respiratory therapists, phlebotomists, and other direct care
and non-direct care workers to do critical work.
I am a service-connected veteran myself and a large number
of our employees that work at the VA are service-connected
veterans who provide outstanding service to our men and women
who served their country honorably.
I am here in front of this honorable committee to request
investigations into a number of disturbing and preventable
situations that occurred at the Jackson VA Medical Center.
Over the years, management has consistently been
inconsistent in responding to staffing problems. Since 2003,
AFG Local 589 has repeatedly requested that the VA leadership
address short staffing and nursing personnel and a number of
inpatient wards, particularly 2A, the surgery ward, and other
wards. Management made a few improvements despite our many
requests.
On April 1st, 2011, a veteran, a long-time employee by the
name of Johnny Lee, who I knew personally, bled to death on 2A,
the surgical ward.
This year, September of 2013, I was informed during a staff
meeting that we had 14 patients fall in the month of September,
14 in one month.
I talked to the head nurse on that floor. I asked her about
staffing. She acknowledged that they had a staffing problem.
She also acknowledged that leadership was aware of the staffing
problem.
Local 589 also filed multiple requests to the division
director, Ms. Rica Lewis-Payton, and our current center
director, Mr. Joe D. Battle, to request investigations into
incidents of nepotism involving our chief nurse exec who is
currently not in that job, Ms. Dorothy M. White-Taylor, and
some of her deputy chief nurses.
Since 2012, AFG Local 589 has sent 12 written requests to
the medical center director to investigate alleged violations
by several members of his management team. Unfortunately,
leadership has been very reluctant to address alleged
violations of rules and regulations by certain members of their
own team in comparison to complaints against regular employees
which would be investigated quicker.
Despite numerous requests, management waited more than one
year to launch an investigation into the improper hiring
practices of Ms. Dorothy M. White-Taylor. Currently that is
ongoing according to Mr. Battle in a memoranda I received from
him dated in September.
VA leaders have also failed to hold a service chief of
medical administration service accountable for giving employees
unauthorized access to veterans' my healthy vet account.
Giving these employees this unauthorized access was a
privacy violation of these veterans. Veterans were enrolled
into my healthy vet account without their own approval or their
own knowledge.
These actions constitute a clear violation of patient
privacy and breach the sacred trust that our veterans expect
and deserve. The veterans who receive their care at the G.V.
Sonny Montgomery Medical Center and dedicated employees whom
care for them truly deserve an investigation of the concerns
raised by AFG Local 589.
Thank you all for giving me the time.
[THE PREPARED STATEMENT OF CHARLES JENKINS]
* G.V. ``Sonny'' Montgomery VA Medical Center in Jackson,
MS has suffered for many years from understaffing of nursing
positions, nepotism in hiring of nursing positions and other
harmful management practices that have hurt patient care and
employee morale.
* AFGE Local 589 has repeatedly requested that management
at the facility level and the VISN level address these issues.
In almost every instance, management has been very slow to
respond and typically has not taken any or preventive measures
or other significant actions to address the problems raised.
* Understaffing in several areas of the facility has led to
an increase in patient falls.
* Leadership at the VISN and facility levels have not held
management accountable for providing unauthorized access to My
Healthy Vet that resulted in violations of patient privacy and
improper manipulation of enrollment data.
* Several managers have engaged in illegal nepotism by
hiring their immediate family members to fill nursing positions
at this facility, and have not been held responsible for their
actions despite repeated requests by Local 589 for an
investigation.
ADDITIONAL STATEMENT OF MR. JENKINS
STATEMENT OF CHARLES JENKINS, PRESIDENT
AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES LOCAL 589
G.V. ``SONNY'' MONTGOMERY VA MEDICAL CENTER
JACKSON, MISSISSIPPI
BEFORE
HOUSE COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
NOVEMBER 13, 2013
Chairman Coffman, Ranking Member Kirkpatrick and Members of
the Subcommittee:
Thank you for the opportunity to testify today on behalf of
Local 589 of the American Federation of Government Employees
(AFGE) regarding understaffing of nursing personnel, nepotism
in hiring and other practices that have adversely impacted
employee morale and patient care at the G. V. ``Sonny''
Montgomery VA Medical Center in Jackson, Mississippi.
I have served as President of AFGE Local 589 since 2001. I
have worked at the Jackson VA Medical Center for 18 years as a
housekeeping aide, nursing assistant, and most recently,
medical supply technician.
I am a service-connected disabled veteran who served in the
Navy. Many of my coworkers also represented by AFGE are
veterans who consider it a great honor to take care of other
veterans as VA employees.
The front line employees represented by Local 589 are
hardworking men and women who do their best to provide
exemplary service to our Nation's Veterans. We have become
increasingly concerned about a number of issues, summarized
below. (A more detailed list of requests for investigation
submitted by Local 589 is set forth in the Appendix.)
I. UNDERSTAFFING OF NURSING PERSONNEL
Since 2003, Local 589 has requested that management address
severe short staffing of nursing personnel in a number of
inpatient areas that were resulting in frequent patient falls
and other patient harm. Management has been very slow to
respond and has not taken sufficient action to resolve the
problem. While management has addressed understaffing in some
areas, Ward 2A (where surgery and general medicine patients are
cared for) continues to be very short staffed. On October 16,
2013, Local 589 learned that fourteen patients fell during the
month of September.
II. NEPOTISM IN HIRING OF NURSING PERSONNEL
Since 2012, Local 589 has submitted multiple requests to
the VISN Director and the Medical Center Director to
investigate instances of nepotism involving the Associate
Director of Patient Care Services and several Deputy Associate
Directors hiring their own family members for nursing
positions. Management waited for more than a year to convene an
investigation. On September 30, 2013, the Medical Center
Director informed Local 589 through a memorandum that the
investigation is still ongoing.
III. MANAGEMENT VIOLATIONS OF PATIENT PRIVACY AND
MANIPULATION OF ENROLLMENT DATA IN MY HEALTHY VET
Local 589 also asked management to investigate actions by a
service chief that provided employees with unauthorized access
to the My Healthy Vet accounts in order to artificially boost
enrollment numbers for our facility. Management conducted an
investigation in May 2013 but has not provided us with any of
their findings.
Thank you for the opportunity to share the concerns of AFGE
Local 589.
APPENDIX
> On May 29, 2013, (more than a year after I requested an
investigation) I received a memorandum signed by Center
Director, Joe D. Battle, which states they were appointing an
Administrative Board of Investigation to investigate then
Associate Director of Patient Care Services (PCS) Dorothy M.
White-Taylor for making threatening remarks to me following my
complaint about how she treated employees, her alleged
employment of a nephew in PCS and her alleged receipt of
prescribed controlled substances from certain VA providers.
> On June 6, 2012, Local 589 Vice President Nena P. Jackson
and I sent a memorandum entitled ``Request for Investigation''
to Center Director Joe D. Battle, and Acting Associate Director
of Patient Care Service (PCS) Ms. Thelma Gray-Becknell. Our
memorandum requested an External Administrative Board of
Investigation into the hiring and promotional practices of
Nursing/Patient Care Services, in violation of Center Policy K-
05-37 that restricts the employment of relatives.
> On June 12, 2012, Local 589 Executive Board sent a
memorandum to the Director's office (date and time stamped June
12, 2012 @12:47 noon) which requested an ``External Audit &
Investigation'' to be done in reference to all bargaining unit
promotions and individuals hired by the prior Associate
Director, of Nursing/PCS (Dorothy M. White-Taylor).
> On June 14, 2012, Local 589 Executive Board received a
written response to our June 12, 2012 Request for External
Audit & Investigation. The response was from Acting Chief of
Human Resources Management Service (HRMS) Tracy L. Skala and
stated that the request was being reviewed. We have not been
informed about any other actions since that date.
> On June 14, 2012 @3:14pm I sent six (6) emails with
attachments stating our concerns about staffing and nepotism,
among other matters, to the VISN Director and Medical Center
Director. I was fully aware that Ms. Lewis-Payton and Mr.
Battle were new to their positions. My information to them was
a sincere attempt to inform them about past and current
problems at our Jackson VAMC. On June 14, 2012 @9:33pm, Ms.
Rica Lewis-Payton responded to my email. She stated, ``I am on
travel the next couple of weeks. Please be assured I will
thoroughly review the documents. Thanks for your commitment to
Veterans and the Jackson VAMC.''
> On June 19, 2012, @5:00am I sent an email to Mr. Battle
and Ms. Gray-Becknell discussing mismanagement, abuse of
authority and understaffing, and requesting an external
investigation.
> On June 25, 2012, I sent another email to Director Battle
and VISN 16 Network Director Rica Lewis-Payton requesting an
investigation of the same matters.
> On August 8, 2012 Local 589 sent a second request for an
External Audit, in regards to the hiring and promotional
practices of Dorothy M. White-Taylor.
> On September 4, 2012, during a Labor/Management meeting,
Center Director, Joe D. Battle verbally stated that the Union's
request for an External Audit & Investigation would be honored.
There was no follow up action.
> On September 18, 2012 I sent an email to Director Battle
to discuss the Union's request for an External Audit &
Investigation that still had not been done.
> On September 24, 2012, @6:07am, I sent an email to
Director Battle stating, ``I have no faith in this VACO
investigation at this point. If the investigator is Attorney
John Davis (an HR consultant with VHA), I am extremely
disappointed and believe a cover-up is at work.''
> On September 26, 2012, @4:28pm, I sent an email to
Director Battle requesting a written response to the AFGE Local
589's September 12, 2012 memorandum.
> On September 28, 2012, I receive a memorandum from
Director Battle, stating that he had appointed John Davis over
my objections, to conduct a fact-finding inquiry in connection
with the various issues the Union has brought forward.
> On October 17, 2012, @6:01pm, I sent an email to John F.
Davis, Mr. Battle and Ms. Lewis-Payton. I informed them that
the Union disagreed with the ``fact-finding'' Mr. Davis did
regarding the Union's allegations of nepotism.
> On November 14, 2012, @8:22am, Local 589 Vice President
Nena P. Jackson sent an email to Director Battle asking him the
status on the investigation concerning nepotism.
> On December 1, 2012, @3:07pm, Mr. Battle sent an email to
VP Jackson and me. He stated: ``I was given a preliminary
review earlier in November but I asked for more work to be done
so it is still in progress.''
> Mr. Battle waited more than one year before he convened
an ABI against Dorothy M. White-Taylor. (May 29, 2013) He used
John F. Davis as the Chairperson.
> On September 25, 2013, Vice President, Nena P. Jackson
and I sent a memorandum to Mr. Battle, requesting the status of
the ABI done on Dorothy M. White-Taylor.
> On September 30, 2013, Mr. Battle sent the Union a
memorandum stating that the investigation is still ongoing.
> As of the date of this hearing, the Union has not
received any more information on this matter from Mr. Battle.
Union officials were informed by anonymous sources that Dorothy
M. White-Taylor was reassigned to a VISN position.
> Privacy violations:
o On December 7, 2012, I sent a memorandum to Center
Director Battle, requesting an External Board of Investigation
against Chief of Human Resources Office Management Services,
Tiffany S. McFadden. Local 589 alleged the following violations
against her: abuse of authority, violation of agency
regulations and rules, violation of Privacy Act and Medical
Center Policy Number B-136-25, gross mismanagement, violation
of law against ``Prohibited Personnel Practices'' , 5USC
Section 2302(b) (6). The memorandum also provided witness
statements from six (6) employees.
o On December 10, 2012, the Chief of HRMS, Tiffany S.
McFadden openly admitted to Jessie J. Thompson, President of
SEIU, and me that she had assigned her husband (a non-employee)
to work in a sensitive area of HRMS reviewing sensitive
information.
o On December 11, 2012, during a Labor/Management meeting,
I spoke with Center Director, Battle, and other PENTAD Leaders,
regarding Ms. McFadden's admittance of having a non-VAMC
individual (her husband) in a sensitive area. I further
explained how she forced employees to work overtime without
negotiating, and how her husband, a non-VA employee was
reviewing sensitive information that had employees' names on
it.
o On December 13, 2012, @9:29am, I sent an email to Ms.
Rica Lewis-Payton, Mr. Battle and other PENTAD Leaders. I asked
Ms. Lewis-Payton for her assistance, and requested that she
investigate Ms. McFadden's conduct.
o On December 14, 2012, I spoke with Ms. Rica Lewis-Payton
via telephone. I mentioned to her the Union's concerns about
Ms. McFadden forcing employees to work overtime, and having her
husband in a sensitive area of HRMS, and reviewing employee
information. Ms. Lewis-Payton made a statement to me about this
being a ``witch hunt''. Later on that same phone call, Ms.
Lewis-Payton stated that there is no further need for an
investigation into my allegations.
> Nepotism: On January 8, 2013, @7:30pm I sent an email to
Mr. Battle and Ms. Lewis-Payton, informing them that an
employee hired by Ms. McFadden had the same mailing address as
Ms. McFadden. It was alleged that the employee is related to
Ms. McFadden, which would constitute a violation of the law
``Prohibited Personnel Practices'' if proven true.
> On January 9, 2013, @2:44pm I sent an email to Mr. Battle
and Ms. Lewis-Payton, in which employees had witnessed Ms.
McFadden's husband in a sensitive area of Human Resources
again.
> On January 10, 2013, I was verbally informed by Mr.
Battle that Ms. McFadden would be detailed out of HRMS and an
ABI would be convened.
> On January 13, 2013 @04:24pm, I sent an email to Mr.
Battle, thanking him for detailing Ms. McFadden out of HRMS and
deciding to convene an ABI.
> On January 22, 2013, I received a memorandum from Mr.
Battle informing me that an ABI would be done regarding the
allegations that AFGE Local 589 brought forward about Ms.
McFadden, Chief of HRMS. The allegations were: hostile working
environment prohibited hiring practices by Chief of HRMS,
fraternization by human resources management, unauthorized
access to Human Resources by visitors, and mismanagement of
HRMS processes by HRMS Leadership.
> On March 27, 2013, May 6, 2013, June 10, 2013, and
September 25, 2013 I sent a memorandum to Director Battle
asking for the status of the ABI on Ms. McFadden, and the
recommendations from the ABI.
> On October 9, 2013 I received a memorandum in the AFGE
mail slot, predated June 18, 2013. It stated, ``Once the
actions of the Board have been completed we will process your
request under the Freedom of Information Act.'' This was signed
by Center Director, Battle.
> On April 11, 2013, @5:11pm I sent an email to Center
Director Battle requesting that Medical Administration Service
Fred A. Nichols be investigated. My emails provided
documentation of some of Mr. Nichols' past inappropriate
conduct.
> On April 22, 2013, I sent an official memorandum
requesting an External Investigation against Fred A. Nichols,
for the following allegations: bullying and disrespectful
conduct, mismanagement and abuse of authority.
> On May 29, 2013, Director Battle sent me a memorandum,
stating that an ABI was being appointed to investigate the
following allegations regarding Fred A. Nichols; hostile work
environment, privacy violations pertaining to MyHealthyVet and
abuse of authority.
> On September 25, 2013, AFGE Vice President, Nena P.
Jackson and I sent a memorandum to Mr. Battle, requesting the
status of the ABI done on Fred A. Nichols.
> On October 9, 2013, the Union received a predated
memorandum (dated September 30, 2013) in the AFGE mail slot. It
stated, ``As of this date, the investigation on the Chief, MAS
is still ongoing.''
> Request for an Investigation against prior Acting Chief
of Pharmacy Service, James H. Whelan: On June 21, 2013, I sent
a memorandum to Center Director Battle, (date and time stamped
@ 2:36pm) requesting an External Investigation (ABI) against
James H. Whelan, Acting Chief of Pharmacy Service for abusing
the leave of pharmacy techs and other employees we represent.
> On October 9, 2013, @6:46pm I sent an email to Mr.
Battle, entitled ``Following up on issues of importance''. I
mentioned that the Union's request for an ABI on James H.
Whelan had not been replied to.
> As of the date of this hearing, the Union had not
received a response from Mr. Battle regarding our request for
an ABI on James H. Whelan. Mr. Whelan is no longer Acting Chief
of Pharmacy Service, but I was told he is still in a management
role.
> Concerns about understaffing during Dorothy M. White-
Taylor's tenure as Chief Nurse/Associate Director of Nursing/
Patient Care Services:
o On September 18, 2003, AFGE Local 589 officers sent a
memorandum to Chief Nurse, Dorothy M. White-Taylor and Center
Director, Richard J. Baltz. We requested the Nurse Staffing
Plans for all inpatient wards (4CS, 4CN, 2A, Ground Floor
Nursing Home, First Floor Nursing Home).
o On February 5, 2004, Center Director Baltz proposed a
Pilot Program to address patient falls to start in the GFNH -
Ground Floor Nursing Home. The program would utilize log sheets
to ensure that patients are observed every hour, and staff are
assigned hourly rounds.
o On February 18, 2004, AFGE Local 589 responded to Center
Director Baltz, stating the fact that AFGE had more than two
years of continual communication with Chief Nurse Dorothy M.
White-Taylor and the Center Director in regards to staffing
needs, and that the union had repeatedly communicated their
concerns about the impact of short staffing on patient falls.
o On March 30, 2004, the union sent emails regarding gross
staffing problems in the Ground Floor Nursing Home. We sent
these emails to Dorothy M. White-Taylor, Prior Chief of Staff,
Kent A. Kirchner, and Rosa T. Garner, (one of the Deputy Chief
Nurses).
o On September 16, 2005 I sent emails to Dorothy M. White-
Taylor, Rosa T. Garner, Acting Center Director, Rebecca J.
Wiley, in regards to inadequate staffing levels and other
deplorable working conditions in the Ground Floor Nursing Home.
o On December 29, 2005 @11:03am I sent an email to
Associate Director, James Pasquith in regards to the fact that
no one from the Chief Nurse's (Dorothy M. White-Taylor) or
Center Director's office had contacted Union officials
regarding the September 16, 2005 email addressing staffing in
the GFNH.
o On June 5, 2005, @05:02pm, I sent an email to GFNH Head-
Nurse, Jerrie Williams in regards to meeting with her and GFNH
Staff, on June 17, 2005 to discuss staffing and other concerns.
o On January 5, 2006, Union officials filed a 2nd step
Grievance against Dorothy M. White-Taylor in regards to
unhealthy and unsafe working conditions in Ground Floor Nursing
Home and First Floor Nursing Home.
o On February 10, 2006 Union officials received a written
response from Chief Nurse Dorothy M. White-Taylor. She stated:
``I have reviewed information on the current staffing in the
NHCU and shared it with the Center Director. He has also
reviewed the information and discussed it with me. And although
staff levels have met the required patient care hours, senior
management has made the decision to add additional nursing
assistants to enhance the current staffing levels. This staff
will allow the NHCU Head Nurses to schedule three (3) nursing
assistants (rather than 2 nursing assistants) for each hall on
the day and evening tours when the patient care activity is
high. Licensed staff will also be added to ensure patient care
is well coordinated with the additional direct patient
caregivers in the NHCU.''
o On February 13, 2006 AFGE Local 589 Vice President Nena
P. Jackson (then Nena P. Davis) and I sent a memorandum
proposing nineteen (19) items that AFGE Local 589 and staff in
the FFNH & GFNH, thought would improve employee morale and the
working environment. This was delivered to Dorothy M. White-
Taylor, and Center Director, Richard J. Baltz.
o On January 24, 2008 I sent a memorandum to Director,
Baltz, and Chief Nurse Dorothy M. White-Taylor, requesting to
meet to address staffing concerns and other issues.
o On September 22, 2009, during a Labor/Management meeting
with Center Director, Linda F. Watson, and Chief Nurse, Dorothy
M. White-Taylor, Union officials brought to their attention
staffing shortages on Wards 4CNorth, 4CSouth, FFNH, and 3K.
o On October 1, 2009, @1:26pm, I sent an email to Dorothy
M. White-Taylor, Center Director, Linda F. Watson, Chief of
Staff, Dr. Kent A. Kirchner, and Associate Director, Shannon C.
Novotny informing them of inadequate staffing in the ENT
Clinic.
o On January 14, 2010, @6:22pm, I sent an email to Center
Director, Linda F. Watson, and VISN 16 Network Director, George
Gray, in regards to serious understaffing in the Supply
Processing and Distribution (SPD) Section of Decontamination.
(Dorothy M. White-Taylor managed this area as Chief Nurse).
CURRICULUM VITAE
Charles Jenkins has served as President of AFGE Local 589
at the G.V. ``Sonny'' Montgomery VA Medical Center in Jackson,
Mississippi since 2001. He previously held other offices with
Local 589.
Mr. Jenkins started working for the VA in 1995 as
housekeeping aide. His other positions at the VA include
nursing assistant and medical supply technician.
Mr. Jenkins is a service-connected disabled veteran of the
Navy. He was born and attended school in Cleveland, Ohio. Mr.
Jenkins has been married for 24 years and has three children.
Mr. Coffman. Thank you, panel, for your testimony.
Dr. Hollenbeck, what policies were in place at Jackson VAMC
that pertain to the prescription of narcotics?
Dr. Hollenbeck. In primary care, the bulk of the patients
were seen by nurse practitioners. The nurse practitioners do
not have individual DEA registration numbers as required by
federal and state individual law, licensing laws.
They used an institutional DEA number, which was an
umbrella, which also meant you could not really trace, except
with a little more investigation, who was prescribing or over-
prescribing narcotics. These NPs again also did not have
physician collaboration.
When Ms. White-Taylor was arrested, the NPs were suddenly
not allowed to write narcotic prescriptions because the DEA got
wind of what was happening and swept in. We were then told as
physicians, the few of us left, there were three of us at that
point, that we needed to sign narcotic prescriptions on
patients we did not see.
Email documentation abounds and it was that you are not
helping the veterans if you do not do this and you are not a
team player. But that is illegal and I immediately had called
the DEA and they said it is illegal. So I refused.
The scheme then was to have the residents from the
University of Mississippi Medical Center and this was done with
the chief of staff, Dr. Kent Kirchner, the then chief of
primary care, Dr. James Lochere, and the chief of medicine, Dr.
Jessie Spencer, and they assigned residents after hours to look
at charts to write narcotic prescriptions.
Those residents actually could have been arrested on the
spot by the DEA. I was told that personally by Jeff Jackson,
the agent. All of this was illegal. It was one scheme after
another.
And also, as we all know, narcotic over-prescribing is a
major concern along with mental health brain active chemicals.
All of this was a setup for disaster.
Mr. Coffman. Thank you.
Dr. Sherwood, when did Jackson VAMC management become aware
of the radiology misdiagnosis made by Dr. Kahn and what steps
have they taken since then to properly address and correct
their effects?
Dr. Sherwood. I have been gone for a couple of years, but
let me give you the chronology as I know it from the trial
transcripts primarily.
Dr. Kahn joined the VA in August of 2003. The first month
he was there, he broke a wire off doing an invasive procedure
in the femoral artery of a patient. And although it was known,
he started to send that patient home.
Two of the invasive procedure room technicians went to Dr.
Margaret Hatten to report that the patient was about to be sent
home. She intervened so that that patient was taken care of. So
this was within the first month that he was there. This was
September 2003.
The same week, and he had done a partial neuroradiology
fellowship at that point, but he missed a broken neck in a
patient during the same month. And at that point, according to
the trial, his supervisor, the chief of radiology, was informed
that this young man just right out of training was having some
problems. Apparently they were told that he would monitor the
situation, that the chief of radiology would.
Between 2004 and 2005, departmental radiologists, according
to the record, went individually to the chief of radiology to
report these errors that were continuing to crop up. Initially,
according to the trial record, the chief of radiology continued
to say he would monitor the problem.
But towards the end of that period of time, he basically
said that the people who were reporting to him were the problem
and that they needed to leave him in charge of everything and
to leave him alone effectively.
Between 2005 and 2006, there was a flurry of emails from
the chief of radiology and the chief of staff about stressing
productivity, meaning getting as many RVUs per radiologist as
possible in the department. And at that point, Dr. Kahn was
held up as a model of productivity to the other radiologists.
February 2007, Dr. Hatten sends the list of 52 names of
patients that were major errors and in her opinion showing that
Dr. Kahn was outside the norm of expected errors from a
radiologist to the Office of Inspector General. This list of
the 52 names later became Plaintiff's Exhibit Number 25 in the
federal trial.
April of 2007, the hospital director refused to meet with
the concerned radiologists over what was going on in their
department, the fact that managers were not taking any action
as a result of this threat to what they considered patient
safety.
However, the chief of staff did meet with the three female
radiologists. Actually, I think at that meeting, there were
four if my recollection is correct, three who later were
plaintiffs in the trial, and at that point, issues a veiled
threat to their jobs, basically saying if I had more
radiologists like Dr. Kahn, we would not need your three
positions effectively.
Sometime during the period between April and June, the
Jackson VA Medical Center in trying to respond to these
allegations about Dr. Kahn sends a simple small number of
cases, 30 cases to the chief of radiology at the Houston VA
Medical Center to see if they can find any errors of Dr. Kahn's
that were significant.
In my written testimony, I point out, and in my Office of
Special Counsel response, whistle blower response, that this is
an extraordinarily small number and had no statistical power to
really pick up anything.
In fact, the chief of radiology at Houston writes back and
said seems to be a competently trained radiologist, but seems
to be in quite a hurry when he is doing these interpretations.
Then in June, between the 26th and the 28th of 2007, the
OIG has a site visit. They recommended----
Mr. Coffman. Dr. Sherwood, I am afraid I am going to have
to move on. Just let me ask you one question. The reason why
Mr. Kahn was moving so fast through these, through reading
these, I guess, radiology reports, these images----
Dr. Sherwood. Yes.
Mr. Coffman. --there was a financial incentive built in;
was there not?
Dr. Sherwood. That is correct.
Mr. Coffman. Okay.
Dr. Sherwood. Yeah. I apologize for the length of my----
Mr. Coffman. No, no problem.
Ranking Member Kirkpatrick.
Mrs. Kirkpatrick. Thank you, Mr. Chairman.
Dr. Hollenbeck, I am a former hospital attorney and I was
in charge of the credentialing committees, the peer review
quality assurance, and so I am very interested in what is going
on with the nurse practitioners at this hospital.
Is there a credentialing, an Allied Health practitioner
credentialing committee at the hospital?
Dr. Hollenbeck. There is. And there is another OSC
complaint as I understand about credentialing and privileging.
I do not sit on that committee.
I do know that and at the present time, my understanding is
that management is scrambling to check off the requirements in
the Office of Special Counsel report that there be oversight of
the nurse practitioners as state law requires. And as Major
Hearon said, some of them have gotten Iowa licenses where they
do not need supervision suddenly.
Mrs. Kirkpatrick. And with an Iowa license, can they
practice in Mississippi?
Dr. Hollenbeck. This is an open question and I brought it
up including to Mr. Battle two weeks ago at a meeting with
physicians and other bylaw review.
The Iowa State Nursing Board of Registration says that if
you practice in Iowa, you do not need collaboration, that 50
states have a gobbledegook of----
Mrs. Kirkpatrick. Yes, they do.
Dr. Hollenbeck. --certifications. So----
Mrs. Kirkpatrick. Yes. And so what is the requirement in
Mississippi?
Dr. Hollenbeck. Well, in Mississippi, they must have a
signed collaborative agreement. They must have a certain
percentage of charts reviewed every month, a log kept, and also
quarterly face-to-face review. None of that has been done. And
one doctor, Dr. Spencer, has 10 to 14 nurse practitioners and
the limit is four.
And Iowa has also stated that if you practice outside of
Iowa, you should follow the laws of the state you are
practicing in. So, again, we need to know.
Mrs. Kirkpatrick. So the physician to nurse practitioner
ratio is very unusual. Why do you think that is----
Dr. Hollenbeck. Well----
Mrs. Kirkpatrick. --at this particular hospital?
Dr. Hollenbeck. --historically, and it is more detailed in
my written testimony, my whistle blower comment, Dorothy White-
Taylor wanted to have the department of primary care all nurse
practitioners.
And she set up the idea that the nurse practitioners did
not need supervision, that the collaborative agreements were
just a piece of paper. The chief of staff went along with it.
And physicians really were pushed.
I was too stubborn and I wanted to be there and I wanted to
work with the veterans. You know, our lives were made very
uncomfortable by overloading in particular.
Mrs. Kirkpatrick. Not to push you or interrupt you, but she
is not there anymore. Am I right?
Dr. Hollenbeck. That is correct.
Mrs. Kirkpatrick. Okay.
Dr. Hollenbeck. We had----
Mrs. Kirkpatrick. So----
Dr. Hollenbeck. Go ahead.
Mrs. Kirkpatrick. --if you had to name the top three
challenges facing the hospital right now under the new
leadership team that has been there a little bit over a year,
what would you say are the top three challenges, not going back
and rehashing the past, but looking toward the future?
Dr. Hollenbeck. Reorganize the primary care department to
have more physicians and when a physician comes as we had
someone several months ago, do not ask them to break narcotic
law again, do not overload their schedule as they did with me
and several other physicians, and then----
Mrs. Kirkpatrick. Are you saying physician recruitment is a
problem in Mississippi?
Dr. Hollenbeck. Yes. And it is a problem now because the
word is out about the hospital.
Mrs. Kirkpatrick. Is it a problem just at this hospital or
in Mississippi overall?
Dr. Hollenbeck. I only know about the Jackson VA.
Mrs. Kirkpatrick. Okay.
Dr. Hollenbeck. And I moved there to work with the
veterans. And the doctor who quit a couple months ago moved
from New York City to come and could not stay after two months.
Mrs. Kirkpatrick. Okay. Mr. Jenkins, thank you for your
service to our country.
I just want to ask you a little bit about leadership at the
VA. You testified that it has been inconsistent.
If you were going to have the ideal leadership team at the
VA, what would that look like?
Mr. Jenkins. It would have to be someone that is familiar
with veterans' needs. We are not just regular patients. We have
special needs.
I come to the VA myself as a patient and I want to go on
record saying that we do have some outstanding workers there.
And I do not agree with any part of the VA being privatized.
So we have to have someone that is dedicated to keeping the
Federal Government running, keeping our medical center running,
but understanding veterans' needs.
Also individuals that do not mind going out and walking
around a hospital and finding out what the veterans need,
finding out what the staff need, retaining staff, even the
lower graded staff. I used to be a housekeeper. I was a WG1. I
was a nursing assistant. We need to not have someone there that
forgets about those individuals.
That is one of the reasons why I brought out to them and
committee Members the nepotism because we had a chief nurse who
was allowed to abuse her authority and hire family members,
allegedly hire family members and let some of her deputies do
that while a lot of the other employees, regular employee was
doing their job, dedicated to our veterans, were just in the
positions knowing we could not get promoted unless we knew
someone or was something special.
Mrs. Kirkpatrick. And I understand that was a problem in
the past. Do you see that as a problem with the current
leadership team?
Mr. Jenkins. I see the current leadership team right now.
They need to be more focused on doing more for what is going on
now. And what I mean by that, ma'am, as far as understanding
the special needs of our veterans.
I respect Mr. Battle. I respect Ms. Payton. But they have
to have more insight into this and you only can get that by
going down and actually talking to staff, talking to patients,
and finding out what is going on. You cannot take Band-Aid
approaches on situations. I----
Mrs. Kirkpatrick. Thank you, Mr. Jenkins.
My time has run out. Thank you, Mr. Chairman.
Mr. Coffman. Thank you, Ranking Member Kirkpatrick.
Dr. Phil Roe, Tennessee.
Mr. Roe. I thank the chairman and thank all of you all for
your service both at the VA and to our country. Just two days
after Veterans Day, so thank you very much for that.
I, too, am a veteran as many people up here are and live
within a mile of a large VA medical center in my home town,
Johnson City, Tennessee, Mountain Home Medical Center. And I am
very disturbed about the potential quality of care issue.
And, Mr. Jenkins, I agree with you. We should be able to
provide great care for our veterans. And as the general said,
General Hearon said, they have earned those rights. But if we
cannot provide it--and I have been sitting here now for five
years.
I have spent 31 years practicing medicine, five years up
here, and I have become very frustrated in this process because
if we cannot provide those services, the backlog of claims--and
we can spend the rest of the hour talking about what the VA had
not done.
And I agree with you, Mr. Jenkins, there are a lot of great
people. Some of my best friends work at the VA medical center
at home. They have the veterans' benefits and best interest in
their sights every day when they go to work, no question about
it.
But I think one of the concerns I have, Dr. Hollenbeck, and
certainly as a primary care doctor myself, is this supervision
of nurse practitioners. People do not understand and properly
used, a nurse practitioner can be very helpful and provide an
extender for you as a physician.
But the levels of training are not even close in
comparison. When you look at 720 hours of training for
something, that is 20 days. That is nothing. And, I mean, that
is a very little bit of time. I do not want to minimize that.
But certainly why would the ratio of physicians to nurse
practitioners be reversed and why would a veteran go two years
without seeing a doctor?
Dr. Hollenbeck. Mountain Home, Tennessee is where I believe
our prior chief of primary care, Dr. James Lochere, is. And I
do ask that people look into who gave him the recommendations
from our site to go and get another job when he decimated our
primary care department with help.
The ratio, I do think, Ms. or Dorothy Taylor-White or
White-Taylor, Mr. Jenkins referred to her as the chief of
nursing. She had an empire. The empire was enabled by the chief
of staff. The VISN leadership did not step in.
Now, there is a culture where a lot of the physicians are
afraid to speak up against the nurse practitioners. They far
outnumber us. Some of them are very militant and some of them
are wonderful. And some have thanked me for coming forward with
the things that I have said.
I think there is a large nursing lobby in the VA system and
I have been told this many times. And this current proposal to
have them unsupervised across the country, there is a large
amount of documentation that I hope all of you will read, that
push is there. Is it also to save money? I do not know.
Mr. Roe. Well, let me give you just a couple facts that any
medical center ought to be aware of is that there are more
narcotic overdose deaths in this country than are car wrecks
now. It is a huge problem. And to have a group of individuals
practicing unsupervised, and, I mean, I am looking at myself,
too, my own prescribing habits, should be looked at and
evaluated, and exactly the same thing.
And so to have these individuals out there practicing with
narcotic licenses that they do not have writing prescriptions,
I do not know how somebody did not end up in jail.
And, Mr. Jenkins, I do not know how you as a--I mean, not
you, but how me as a practitioner or a hospital that provides
care, provider I should say, could look at Mr. Lee's family and
to see him because I have used wound vacs for years. And to see
that man, to go talk to that family, how you would explain to
them the neglect that occurred for that to happen. That is
incomprehensible to me.
And back to the radiological things, look, we as doctors
rely on adequate and proper radiological evaluations because we
make some pretty big clinical decisions based on what those
things show. And as a matter of fact, we do some big operations
on things for people that they show.
I think that was to me where you looked at 52 cases, if you
had a problem, you should have evaluated a far larger sample of
that to find out if there was an issue. Maybe there was not an
issue.
And the other thing I want to mention before my time runs
out is why wouldn't, and we will get this with the second
panel, is I do not understand why the medical center, the VA
medical center there in Jackson wouldn't go ahead and let the
Mississippi Board of Licensure just look at those things.
I mean, that clears you completely. You have got an
unbiased second group of people that look and it is not HIPAA
and it is not all that. It is nonsense. You should allow them
to look at it. If you have nothing to hide, fine. Look at it
and you are exonerated.
Any comments?
Dr. Sherwood. The only comment I would like to make is to
make sure that a mis-impression listening to my colleague's
comment to the ranking member was that Dot Taylor is no longer
with us. It is true she is not in our hospital facility. If I
am not mistaken, and Ms. Payton can correct it, she was
promoted to the VISN staff where she is employed today. But I
agree with everything Phyllis has said.
Mr. Roe. Thank you.
My time is expired. I yield back.
Mr. Coffman. Thank you, Dr. Roe.
Retired Sergeant Major Tim Walz, State of Minnesota.
Mr. Walz. Well, thank you, Chairman. I want to thank you
and the staff for putting this hearing together. This is our
most important responsibility.
And I think General Hearon was right as we literally sit in
the shadows of Sonny Montgomery who showed us how to do this.
It is important we get this right.
And I think Dr. Roe's use of the word incomprehensible is
what I see when I read this.
Dr. Hollenbeck, I want to thank all of you for coming
forward on this and I know that whistle blowing is a difficult
situation and thank you for doing it.
Dr. Hollenbeck, have you been at other facilities, other VA
facilities?
Dr. Hollenbeck. I have not worked at other VAs. I did work
in a naval hospital for several years.
Mr. Walz. So your experience, and I think, Dr. Sherwood,
you said the same thing, that unfortunately this has been your
only experience and not a good one.
Dr. Sherwood. I was on the staff at the University Medical
Center in Mississippi for almost three years before I went full
time with the VA.
Mr. Walz. Okay. Well, thank you both for being there.
And I think the next hearing is or the next panel is the
one when we hear from VA and we hear some of these things, the
things you laid out. They have been collaborated with OSC.
I am deeply concerned. I am deeply concerned with Dr.
Petzel's comments after this had already been brought to
notice. This is not a kerfuffle. This is an incredible breach
of trust and, as Dr. Roe said, we do not throw the term around
lightly, potentially criminal.
And that is a very important responsibility that we have to
have. And I think by having this hearing, we are making it
clear we have to get there.
I am just most concerned with how we get institutional
problems that allow this to happen for extended periods of
time. That deeply troubles me.
And also, Dr. Hearon, I appreciate your service and your
comments, but I cannot leave unstated where you made some
assessments and took a long portion of your testimony.
Are you familiar with the comprehensive review of the
literature by Hendricks & Nugent on the cost of VA healthcare
as opposed to the private sector?
Major General *Hearon.* No, sir. I probably should be and I
will be soon.
Mr. Walz. Did you take pharmaceuticals into your
accounting?
Major General *Hearon.* I took everything that was in the
VA's budget submission to the Congress.
Mr. Walz. The reason I bring this up is is that I think
your passion for this, and you are absolutely right, I would be
furious with Sonny Montgomery, and your service to the State of
Mississippi and your veterans deserve better than this.
The only thing I would ask you is if you have not ever been
in the Minneapolis VA or the Sioux Falls VA or the Rochester,
Minnesota CBOC that sets in the shadow of the Mayo Clinic, they
will tell you best care you can receive anywhere.
And I have great concerns, I tell you, when I hear someone
say, and I am not against getting the most competition, getting
where we can get out of this, but the core mission of the VA
when people say privatization, there is a reason that no
veteran service organization in this Nation will say
privatization of medical services. So I cannot leave that
unchallenged.
Major General *Hearon.* I do not blame you for challenging
that. It was not a financial reason for suggesting that we look
at it. It was because in the cases of Dallas, Atlanta, Jackson,
Pittsburgh, Buffalo, and so on, these problems keep coming up
like a big Whac-A-Mole game.
If the VA cannot get their organization under control--and
by the way, I meant to mention I think Secretary Shinseki needs
to resign. He has failed in his leadership completely.
Mr. Walz. Well, now we have another line of questioning
from me.
Major General *Hearon.* Oh.
Mr. Walz. But what I would say is are you familiar with the
IOM study on the private sector, the 98,000 deaths?
Dr. Roe is right. This is not something that is just
inherent to the VA. And I bring this up not in any way because
trust me on this. This next panel, they are not going to be
dismissed from responsibility. They are not going to be
dismissed for questioning.
But I think the reason I bring this line of questioning up
is is that I think it weakens our attempt to fix the system
when we do a gross generalization across a large spectrum
instead of focusing on the inherent problems, as the ranking
member said, of how do we move forward and correct this because
this story with Mr. Lee, I do not even have words.
How in God's name can any of us look at his family after
that? If that is being repeated, there is a problem. But what I
can tell you is the incidence of that happening in a Sioux
Falls or Minneapolis is remotely different than this situation.
So I----
Major General *Hearon.* The Joint Commission reviewed that
death of Mr. Lee and they did not find anything wrong.
Mr. Walz. And that is a problem. And you are right and I
think your focus, and I do not want to get on this, I just said
it because you are on to something here, Dr. Hearon. I do not
want you to go on a track that weakens our argument on this.
I think your point on management on this is where it comes
to because I am convinced, and I see physicians there and you
heard from these folks there, for the most part, there is
quality people, but supervision of removing non-quality people
or staffing issues, that is a big problem.
And the thing that concerns me the most is this committee
and the American taxpayers have made the commitment to fully
funding and having the right people on deck at the time when
they need it. And if it is not happening, that is a management
issue. That is not putting resources where they need to be in
the best interest of the country. And that is a valid point
that needs to be found out.
And so I do not want to go too far down that, but I am
deeply concerned once we do that and the question of how far up
responsibility goes is valid. I will say that. And I just think
it is critically important for this committee to find out now
and implement changes so this is not perpetuated.
And this situation, if this was a management problem that
has now transferred to Mountain Home, that is a huge issue of
who is involved here because I do believe this is--this sounds
to me very personnel, culture oriented.
I yield back.
Mr. Coffman. Thank you, Mr. Walz.
Just let me say very quickly before deferring to Dr.
Huelskamp from the State of Kansas that this subcommittee dealt
with the issue of infectious diseases, pathogens, and put the
VA under state regulation in that area. And I think that after
this hearing, I am convinced that there are other areas that
they ought to be subject to state regulation too.
Dr. Huelskamp.
Mr. Huelskamp. Thank you, Mr. Chairman.
A question for Dr. Hollenbeck. What was the structure of
performance pay and bonuses when you were employed at the
Jackson VAMC and were they made contingent on signing
collaborative agreements?
Dr. Hollenbeck. Part of the performance pay, it varies in
departments, so in primary care, the chief of staff, who at
that time was Kent Kirchner, set in place, and supposedly we
voted on it, but we did not, and it was about customer service.
And, of course, we do not hire the clerks. We do not control
them.
Also, all your diabetics had certain numbers showing they
were successfully treated, although we do not go home with the
patients. And God bless them. They do not all take care of
their diabetes.
Once the nurse practitioners lost the ability to write
narcotics and they were all facing--in Mississippi, they all
needed to renew their licenses by the end of the year, 2012,
Dr. Gregg Parker, Mr. Battle, and the acting chief of staff at
that time stood up at a meeting and told us, the physicians,
that 50 percent of the possible performance pay was off the
table unless we signed collaborative agreements.
And those doctors that did not have Mississippi licenses
would have to get them and then not be able to sign the
collaborative agreement. So essentially a gun was held at our
head. A physician said it is our license. We are putting our
license on the line. Dr. Parker and Mr. Battle said it is just
a piece of paper, do not worry about it. When one of the
physicians said but what if something happens in that nurse
practitioner's care and we did not get to oversee them, they
may not even be in our department, Mr. Battle and Dr. Parker
said, well, you can write a letter to the national practitioner
data bank where all these things would be reported forever
about our license and that is stunning.
So the lack of ethical understanding, it is patients' lives
and it is our licenses which mean everything to us. But they
needed to deal with their mess with all of the unsupervised
nurse practitioners who needed a collaborative agreement but
the hell with following the law about it. And excuse my
language.
Mr. Huelskamp. Thank you, Doctor. Very troubling on that.
The information that was provided by this Dr. Parker and
those discussions, was this all in writing or were these verbal
statements to the physicians that if you did not sign these
collaborative agreements, we are going to dock your pay or
actually remove your bonus?
Dr. Hollenbeck. There are minutes that curiously did not
come out from that meeting for six months. Many, many people
were there. I was there. We then received the collaborative
agreements or the, excuse me, the agreements about our
performance pay and if you did not sign it and it did say you
had to be willing to sign a collaborative agreement, so it was
in writing what the deal was.
Mr. Huelskamp. And these bonuses, what would be the range
of these? Do you know that, Doctor?
Dr. Hollenbeck. I would say, and, again, I think it varies
in department, but I think for most departments it might be up
to $10,000. It is not $63,000----
Mr. Huelskamp. Uh-huh. Okay.
Dr. Hollenbeck. --like some management.
Mr. Huelskamp. Yeah, I know. Thank you, Doctor.
One follow-up. Mr. Jenkins, this thing is very troubling,
particularly with the group that you do represent. Your
thoughts on these types of ways to, I think, manipulate
employees of the VA.
Mr. Jenkins. I think it is extremely disturbing because,
like I said earlier, the employees that we represent coming to
the VA, they come to do their job. A lot of those employees are
veterans. And, you know, when you have management in certain
positions that abuse that authority, the employees are
basically held hostage. You cannot make them do what is
correct.
Just like Dr. Hollenbeck being here as an employee and
bringing out some information, the same thing as myself. I am
an employee. I am a veteran. And we want to see change. We want
to see leadership change our medical center for the better.
And I agree with committee Member Walz that, you know, we
should not privatize. We have to be committed to fixing the
system. And we know it can be done. I believe it can be done.
Mr. Huelskamp. Are these physicians members of your
organization in general or not?
Mr. Jenkins. I do not represent the physicians. I represent
the licensed practical nurses and some of the other so-called
nonprofessionals.
Mr. Huelskamp. Do they have similar stories or evidence
that they were being manipulated as well by the VA on the basis
of their performance pay?
Mr. Jenkins. I am unable to answer that question, to give
you the full documents because they are represented by NFFE. So
I cannot give you the----
Mr. Huelskamp. The folks that you represent, though, Mr.
Jenkins.
Mr. Jenkins. Yes, sir. Yes, sir. Some of the folks I
represent have brought me some situations as far as
manipulation of when I mentioned my healthy vet situation. Like
a veteran, I am just going to use my retired general here, if
you come in for treatment and you have an option. My healthy
vet is voluntary. You do not have to sign up for that system.
That system was set up for veterans. It is set up to try to
streamline your checking it. You may be able to go home and
look on----
Mr. Huelskamp. Mr. Jenkins, I am not talking about the
patients. I am talking about the employees that you represent.
Mr. Jenkins. Yes.
Mr. Huelskamp. Have you submitted complaints to the VA on
the basis given what we are hearing, at least for the
physicians----
Mr. Jenkins. Yes, sir.
Mr. Huelskamp. --the use potentially of the performance pay
and bonuses to manipulate perhaps at a criminal level
activities by those employees? That sounds something right down
the line of folks that you represent and defend.
Mr. Jenkins. I sent documents in, sir, regarding nepotism.
But as far as specifics with physicians' pay, I have no
knowledge on that. Even though some of my employees may work
side by side with the doctors, I do not have specific knowledge
on that.
Mr. Huelskamp. I understand. You do not represent the
doctors. But the folks you represent, so complaints about
similar attempts on manipulating their pay or you have not
heard that?
Mr. Jenkins. I have not heard that because my folks do not
receive retention bonuses.
Mr. Huelskamp. They do get bonuses, though, don't they?
Mr. Jenkins. They do not. They get regular, you know,
performance awards and stuff like that, but they do not receive
retention bonuses. It is a different----
Mr. Huelskamp. They get performance bonuses, though,
correct?
Mr. Jenkins. Yes, sir.
Mr. Huelskamp. Okay. And that is part of that bonus. All
right.
Yield back. I apologize for taking too much time, Mr.
Chairman.
Mr. Coffman. Thank you, Dr. Huelskamp.
Dr. Benishek, State of Michigan.
Mr. Benishek. Thank you, Mr. Chairman.
Thank you all for being here this morning.
Like the rest of the committee, I am, you know, frankly
pretty much shocked and amazed by the level of incompetence in
the management it seems in many aspects of the hospital because
we have touched on, you know, wound care, radiology, family
practice. It seems as if the whole hospital was a mess.
Let me ask a question. What exactly is a ghost clinic? I
mean, I could not quite figure that out from reading the
testimony.
Dr. Hollenbeck. I baptized the idea of these vesting
clinics. You will see reference to vesting clinics. Basically
there was a morning report and it would show where the lack of
providers were in the primary care clinics.
And then veterans had waited months and they would have an
appointment. And they would come in and there was no provider
there. They were either moving nurse practitioners around where
they did not have enough doctors or people called in sick.
So the veteran would be there. They would be told there is
no provider to see them.
Mr. Benishek. So, in other words, they were scheduled for
this clinic knowing that there was no provider for that period
of time?
Dr. Hollenbeck. That appointment was left on the books.
Your hairdresser does not do this to you.
Mr. Benishek. And that scheduling, is that a physician
responsibility?
Dr. Hollenbeck. No.
Mr. Benishek. Who handles that department?
Dr. Hollenbeck. No. And that was overseen, you know, higher
than the level of the clerks in the clinics.
Mr. Benishek. You know, this is the problem that we have
run into time and time again. And I kind of appreciate that
Whac-A-Mole analogy that one of you guys made there because it
seems as if nobody seems responsible in the end for the lack of
management and, you know, the horrible testimony we have had
here this morning.
Are any of the people that were responsible for this, are
they still out working at the VA, do you know? I mean, we will
ask----
Dr. Hollenbeck. Well, Dr. James Lochere is not. The chief
of staff stepped down, although he is still involved in some of
the, you know, issues going on. That's----
Mr. Benishek. Is he still employed at the VA?
Dr. Hollenbeck. That is correct.
Mr. Benishek. Yeah.
Dr. Hollenbeck. We have just had a revolving door of acting
chiefs of primary care and acting chiefs of staff.
Mr. Benishek. It just seems to me that there is sort of a
culture of, you know, transferring somebody to a different VA,
you know, after they have had performance reflected here----
Dr. Hollenbeck. Correct.
Mr. Benishek. --which has been inadequate.
Dr. Hollenbeck. Right. And----
Mr. Benishek. And, you know, does anyone here have a
suggestion for the institutional repair of, you know, how do we
fix this institution so that there is better accountability at
the management level for this seeming incompetence?
Dr. Hollenbeck. Well, the thing I would speak to as far as
the medical centers, the center director should have medical
experience. You need to have someone who understands how
clinics run, what it means to walk in and----
Mr. Benishek. Does the chief of staff have input as to how
clinics are run?
Dr. Hollenbeck. I am sorry?
Mr. Benishek. Does the chief of staff have input as to how
clinics are run or is that----
Dr. Hollenbeck. The ultimate responsibility, but it is
usually the service or department chief. So the primary care
chief answers to the chief of staff and they answer to the
director.
Mr. Benishek. So then the chief of staff would be aware
that there is no staff available for that clinic?
Dr. Hollenbeck. Oh, yes. And I have voluminous
documentation of the emails I sent for years.
Mr. Benishek. Let me just go on here because I do not have
much time. Is there a monthly morbidity or mortality conference
at the hospital?
I mean, at my hospital where I work, if there was an
incident where somebody had an alleged care problem, that would
come up at what we call the morbidity and mortality conference
where the physician responsible had to take responsibility for
the problem.
So we would have, you know, reviewers who would review
charts, review x-rays, review the situation so that, you know,
in a learning, collegial, peered setting, you know, we could
improve care over the long term.
Did that occur at this hospital?
Dr. Hollenbeck. Well, I do not know about the inpatient
side.
Mr. Benishek. But you never went to a morbidity or
mortality conference?
Dr. Hollenbeck. No. I was pretty much until nine o'clock at
night in primary care. Dr. Sherwood could answer that question
for you.
Mr. Benishek. Dr. Sherwood, did you ever attend a morbidity
and mortality conference at the hospital?
Dr. Sherwood. We regularly had them on the surgical service
and it was highly selective how these were followed up on. I
could give you one instance, but for the sake of time, I won't
unless you want the specifics.
Mr. Benishek. Well, I am a surgeon as well and I am used
to, you know, in surgery, you know, having morbidity and
mortality conferences so that we can improve care over the long
term or, you know, address an individual who was, you know,
chronically coming up with poor results.
Dr. Sherwood. I think----
Mr. Benishek. So that was a process in the surgery
department?
Dr. Sherwood. I think the service itself tried to
accomplish that, but I think for the overall facility, making
sure your performance numbers were up and good was the
principal goal of everything.
Mr. Benishek. All right. I think I am out of time. Thank
you.
Mr. Coffman. Mr. Palazzo, State of Mississippi.
Mr. Palazzo. Thank you, Chairman Coffman, for having this
hearing and thank the Members for allowing us to participate.
Being from Mississippi, being a marine veteran, serving in
the Mississippi Army National Guard, you know, I take these
complaints extremely seriously. I have been in Congress for two
and a half years and it seems like 90 percent of our caseload
back home is dealing with VA issues and veterans' benefits.
Over 2,500 people my office has served. I have a wounded
warrior fellow who does this probably 60 hours a week. I have
my director of case work is a former army officer married to a
retired colonel. Our number one focus because--it is not just
because my district is extremely populated with military
retirees and active guard installations, but it just seems like
we are breaking one of our fundamental promises to the men and
women who serve our Nation and that is not providing the care
that they deserve, that they have earned.
I am shocked, I am sick, and I am disgusted that we are
even having this and that this is a VA medical center that
bears the name of Sonny Montgomery is not in keeping with his
legacy of service not just to the Mississippi National Guard
but to the Nation. He was a consummate supporter and fighter
for the military.
Dr. Sherwood, you mentioned in your statement that during
the past 15 years, the Jackson VA Medical Center has had a
diverse leadership who all share a common trait, a progressive
failure of their moral compass.
Can you tell me, I mean, 15 years, do they come here and
become morally corrupt or is this systematic throughout the
upper echelons of management through the VA system?
Dr. Sherwood. My first 15 years, the organization really
had no problems. I think patient care was first. Once I saw the
change in the compensation model, we began to see the system
gamed after the first couple of years when managers understood
it.
But when that became paramount, we started to get in these
situations where patients who deserve to be told the truth are
not told the truth. I am referring specifically now to the
trial of 52 people who I cannot speak--you know, I have not
seen their medical record completely. I know what is in the
trial.
But Dr. Hatten certainly has and she certainly believed
after seeing their complete medical record that these were
egregious errors.
I also think that you begin to see the erosion of
cooperation with agencies like the State Board of Medical
Licensure in our state that does have investigative authority
and has a right under exemption, as I understand it, I am not a
lawyer, but I understand they are exempt under the privacy laws
which the current administration of our hospital and the VISN
are hiding behind not to give over the records under the
subpoena from the State Board of Medical Licensure.
And I would hope that one of the results of this committee
today would be to shake those loose for some cooperation with
the State Board of Medical Licensure.
Mr. Palazzo. Thank you, Dr. Sherwood.
And I think Dr. Hollenbeck pointed out briefly that Dr. or
Dorothy Taylor-White is still employed by the VA?
Dr. Hollenbeck. It was a colleague of mine.
Mr. Palazzo. Okay.
Dr. Hollenbeck. I believe Dr.----
Mr. Palazzo. And Dr. Kirchner is still employed by the VA?
Dr. Hollenbeck. Yes, he is.
Mr. Palazzo. And I am looking here. The former director,
Linda Watson, she basically misappropriated funds at another VA
and she was transferred to the Jackson VA.
And this sounds like not just the--can we not only talk
about the executive compensation changes, but is this when the
problems really began at the VA in Jackson as well or was there
leadership issues even before that?
Dr. Sherwood. I can only say that it is an apparent reward
system for people who get good performance measures and do
whatever is necessary in their job. When they get into trouble
for that, then they are taken care of even if it is at some
later date.
I will give you one example. The latest information I have
out of the building, and this is not firsthand, it is
secondary, is, for instance, that Dr. Kirchner has now appeared
at a surgical staff meeting presenting on behalf of the VISN
and the chief of surgery told one of my colleagues that Dr.
Kirchner is now the consultant to the VISN for physician
productivity.
So, again, he appears to be being groomed for a position at
the VISN level. That is----
Mr. Palazzo. That just sounds like the good old boy
network. You know, you are either transferred or you resign and
you become a consultant somewhere within the system. There
seems to be some serious issues with the VA and I do not just
think it is Jackson. I think there are management issues all
across the Nation.
And I hope bringing attention to this one that we can fix
it so no other veterans have to endure the nightmare that they
are going through at Jackson, the fact that Mr. Jenkins lost a
friend.
And thank you for your service as well. You lost a friend,
a fellow employee and a veteran because of gross incompetence
and the people are not in jail? I would like to know everyone
that was involved in that. They should have been fired
immediately.
So we really do in the essence of taking care of our
veterans and also maximizing taxpayer funding for the VA, which
is something we promised to do for our veterans, is that I
would like to think that there are some areas that we could
privatize. And it needs to be explored and maybe dismissed or
accepted.
But we have to look at making sure that your employees, Mr.
Jenkins, the ones that are performing are taken care of and the
ones that are not worth anything, they go find another job, not
in the VA, but in the private sector.
Thank you, Mr. Chairman, for allowing me to be here.
Mr. Coffman. Thank you, Mr. Palazzo.
Mr. Harper, State of Mississippi.
Mr. Harper. Thank you, Mr. Chairman. It is an honor to be
here.
And I want to thank each of you for taking the time to
come, give us these insights.
And, General Hearon, good to see you again. And I know you
have been in my office in D.C. and thank you for your service
to our state, to our country.
And you know on my coffee table in my office is a signed
copy of Sonny Montgomery's autobiography. And he held that seat
for 30 years and, you know, this is something that I know would
make him most unhappy.
And it is something that we want to keep in mind. Our goal
here is we have got a lot of water under the bridge. We have
got a lot of past problems. And the key is what do we do to
make sure that we correct this, we do not deal with this in the
future, and we provide the patient care and remember that the
patients' care is paramount to everything that we do.
And so I want to thank you for your concerns, bringing
these issues to our attention.
And, you know, I think something that Congressman Palazzo
mentioned was the previous director. It appears that many
problems existed when Linda Watson was there, but she had
problems in Georgia, came to Jackson, and the problems were
obviously documented very seriously.
Does anyone know where she is currently? General Hearon.
Major General *Hearon.* I think I heard that she went to
Texas and then retired.
Mr. Harper. Okay. Went to Texas in the VA system and then
retired?
Major General *Hearon.* I believe that is right, but I
think the VISN director would know for sure.
Mr. Harper. All right. Well, we will follow-up on that as
we go forward.
But, Dr. Sherwood, if I could ask you a question. How long
was Dr. Kahn employed by the Jackson VA system?
Dr. Sherwood. 2003 to, I believe, 2008.
Mr. Harper. Okay. Is there a documented time period during
his tenure when he was overlooking images in radiological
studies?
Dr. Sherwood. Overlooking them, he was, yes, according to
the federal trial, yes, including his own statement to that
effect.
Mr. Harper. Well, approximately how many radiologic studies
do you believe Dr. Kahn reviewed during his time at the VA
medical center?
Dr. Sherwood. It is unknown. The estimates were between 15
and 25 thousand depending on his read rate. It is unknown. I
mean, it could be easily found out.
Mr. Harper. There has been much discussion about the 52
individuals, these lives that have been impacted.
And are you telling me then that all 52 have not been
notified of these problems as of today?
Dr. Sherwood. I have no knowledge of what has been done
exactly. I know that two at the time of trial who had
litigation pending, the VA did, yeah.
Mr. Harper. And, General Hearon, would you add some insight
on that?
Major General *Hearon.* I was told that when we first
inquired about this and it was on the basis in addition to the
medical issues, but to the ethical issues involved in having
allegations about 52 and not bringing it to their attention
that some of these people probably had a very painful
unnecessary death.
And they said the case was closed. They were not going back
and reviewing those at all. But we insisted on it. The OSC
helped a lot on this. And two additional institutional
disclosures were made I was told which means that at least they
confessed, you might say, to two additional people. We think
there are more than that.
But a lack of accountability, lack of transparency are some
of the key issues that led to the suffering and death of some
of those patients. And at the time, in the trial, they
estimated the cost would be $300,000 to go back and review all
those records instead of just 100th of one percent. And they
said that it was not worth it.
Mr. Harper. Do you believe that every one of those patients
or their families have a right to know if their images in their
studies were overlooked?
Major General *Hearon.* Absolutely. And the problem is that
by the time some of them got aware of their serious health
issues, it was too late to do anything. And sometimes the
cancers had been--I have talked to some of the veterans--had
nothing to do with that study, but some of them did not know
about it until they went to outside physicians and were told
about it.
And all the processes were in place at the VA or overlooked
like the guy I met last Wednesday. They did blood tests or
blood draws, but they never did what I believe is called a
CA125 test to show that he had had cancer for some time and
they just did not pick up on it even though they were doing the
blood draw.
Mr. Harper. Dr. Hollenbeck, do you believe it is possible
to locate all of these individuals, locate all of the studies
and reevaluate them or at least make the patients aware of the
issues?
Dr. Hollenbeck. It is Dr. Sherwood's area of expertise as
far as that case, but, yes. There were records, some
computerized permanent records.
Mr. Harper. It can be found?
Dr. Hollenbeck. Absolutely.
Mr. Harper. Okay. All right. Thank you.
And I yield back.
Mr. Coffman. Thank you, Mr. Harper.
We will do a second round of questions with this panel.
General Hearon, what measures are you aware of that VISN 16
and Jackson VAMC have in place to promote accountability,
proper training of officials and information sharing to ensure
significant medical errors are prevented and not repeated?
Major General *Hearon.* Sir, I wish I could tell you I knew
of some. I am sure they will be offered by the other panel. But
what I see is like you and I and Command Sergeant Major Walz--
thank you, both of you all--but saw where you send a message to
your troops, so to speak, or your employees, the veterans every
time you do something or you do not do something and the
message is that if you really mess up, you will not be fired
and there is also a good chance you will be promoted to the
VISN office or to another VA medical center or maybe your
highest rank will be removed, maybe temporarily, but there is
no real accountability.
There's no clear punishment and people just looking around
and say why should I be the one to point out the issues. And
thankfully Mr. Jenkins has been doing that for years and others
have been keeping notes. But why should I go through all of
that if nothing ever changes. And the culture of the VA has
just gotten abysmal I am sad to say.
Mr. Coffman. Okay. Mr. Jenkins, how many requests have you
made with Jackson VAMC officials to ask for an independent
external investigation into the alleged wrongdoings at the
facility and what responses have you received?
Mr. Jenkins. From 2012 to the present, I have made more
than 12 requests, 12, and I got three responses that said it is
ongoing. They are looking into my complaints and it is ongoing.
Mr. Coffman. Okay. And no responses, but you have never had
a response that brought about a solution or a conclusion?
Mr. Jenkins. That is correct, sir. That is correct.
Mr. Coffman. Okay. Very well.
Ranking Member Kirkpatrick, Arizona.
Mrs. Kirkpatrick. Thank you, Mr. Chairman.
Dr. Sherwood, what is important for this committee to know
is if there is an adequate accountability structure at this
hospital. By that, I mean credentialing committees, medical
staff bylaws, peer review, quality assurance all the way to the
director.
And so just looking at it structurally, do you think there
is an adequate accountability structure? Let me just clarify--
--
Dr. Sherwood. I missed----
Mrs. Kirkpatrick. --a little bit. It sounds from the
panel's testimony that most of the issues had to do with
particular personnel within that structure, but I want to look
just at--take the personnel out of it, just look at the
structure.
Do we need to make some recommendations to the VA regarding
the accountability structure?
Major General *Hearon.* May I just suggest that the VA has
a core values of I care including integrity and respect and so
on. They need to review those and start following them.
Mrs. Kirkpatrick. Thank you, General. I would like to hear
from Dr. Sherwood too.
Dr. Sherwood. Structural changes only the degree of
absolute power that directors and VISN directors have in the
institution to ignore the processes as they see fit. The
processes themselves, we do not need any more layers of
processes. We need people at the top who have a conscience to
look in the mirror every day and say I want to treat my fellow
person that I am responsible for in this, my job, as I want to
be treated.
Mrs. Kirkpatrick. Thank you for clarifying that. I
appreciate that.
But what would be your recommendations to make sure that we
got that proper person at the top?
Dr. Sherwood. I am going to defer to my colleague.
Mrs. Kirkpatrick. Okay.
Mr. Jenkins. Thank you.
Double standards right now is an issue that is hurting
accountability because on one side, you have top leaders that
is not being held accountable such as like Dr. Hollenbeck
mentioned about our prior chief of primary care being allowed
to go somewhere else or our prior chief of nursing being
allowed to go to the VISN and continue her pay.
The employees that I represent, they are held accountable.
They have progressive discipline. I have had employees removed
for doing things. I have had a number of employees removed.
In my 18 years as a government employee, I have only seen
two low level managers, only two, and they were supervisors who
were removed. But as far as center directors, network
directors, they are moved.
So I feel that double standard need to stop. The same
accountability that the regular employees are held to and they
can be disciplined and fired, that needs to be for the top.
Mrs. Kirkpatrick. Thank you very much.
Dr. Sherwood. I agree completely.
Mrs. Kirkpatrick. Thank you, Dr. Sherwood, and thank you,
Mr. Jenkins. Thank you to the panel and thank you, Mr.
Chairman.
Mr. Coffman. Unites States Army veteran, Dr. Phil Roe,
State of Tennessee.
Mr. Roe. Thank you.
And just a couple of quick questions. I am going to focus
on what I did my entire career, 31 years of practicing is
quality of care.
And one of the things that has disturbed me here is, first
thing is how long does it take to get a primary care visit at
the hospital? How long? If I am a veteran and I move to
Jackson, Mississippi and I call up, when can I get an
appointment?
Dr. Hollenbeck. I think that they keep----
Mr. Roe. Let me back up. When can I be seen?
Dr. Hollenbeck. As opposed to in a ghost clinic?
Mr. Roe. Yes.
Dr. Hollenbeck. Well, I would say that they would tell you
maybe a month, but I know that when I was in primary care, it
could be five to six months. Again, if you wanted a doctor, it
could be even longer.
Mr. Roe. And that was my second question. When would I get
to see the doctor?
Dr. Hollenbeck. It could be six to nine months depending on
how many doctors were there.
Mr. Roe. Would I establish a relationship with that doctor
and continue with that doctor or would I be assigned to a nurse
practitioner typically?
Dr. Hollenbeck. No. There is no team work. There is all
silos of care so that if your doctor has been pushed out--I had
people for four years and there was continuity of care and I
tried to do everything that I was trained to do and hold myself
to a high ethical standard.
But in the last year, there has been eight different
physicians taking care of my panel of patients. And some of my
elderly veterans come up and see me in compensation and pension
and say who will take care of me now.
Mr. Roe. And the second thing, let me just unequivocally
say that there is no way on this planet that I would sign a
narcotics prescription for somebody I had never seen. I mean,
there is just absolutely no way I would ever do that.
Dr. Hollenbeck. That is correct. And I think that when the
VA report tried to say that Dr. Kirchner, Dr. Spencer, and Dr.
Lochere only found out that was illegal and as soon as they
found out a couple months later, they changed the policy, that
is bologna. You know, DEA agent Jeff Jackson said when did you
first learn about that being unethical and I said I knew that
as a medical student.
Mr. Roe. Yeah, you know that. And secondly I certainly
think, as I have stated before, that proper supervision of
nurse practitioners is a way to extend quality of care to
veterans and to anybody. I mean, I use nurse practitioners in
my practice, but we have some very rigid guidelines of which
they were able to practice. And one was not to write a
narcotics prescription without direct supervision.
Dr. Hollenbeck. Correct. That is what I am used to in other
places.
Mr. Roe. And I think the other one that was a little
disturbing to me was the--two things. One was the Medicare. I
mean, typically you have to have--I know how Medicare is and we
have dealt with Medicare patients in my practice. That is very
clear what those Medicare guidelines are. And if you do not
follow those, then you have basically created fraud.
Dr. Hollenbeck. Correct. And I was asked repeatedly and I
refused. They wanted us to co-sign. The nurse practitioner only
would be seeing these patients. I would never see them. The
bottom of the form says I certify they are under my care and I
refused. And each time you sign a piece of paper, each paper is
an instance of fraud.
Mr. Roe. Well, just to give you an example, this has been
almost 40 years ago, I did remedial OB/GYN training. It took me
six years to do what most people do in four because I had a
little drafted status in between. I got two years of service in
between.
And when I came back out of service, Medicaid had gotten
started and you had to have a faculty member present when you
delivered a baby to bill for that. You could not even bill for
it. And so there are ways to do that now without being
fraudulent and convincing yourself that you are providing good
care without proper metrics and supervision.
So that was one. And then I guess the last question and I
will cease is spending all of my career as an OB/GYN doctor,
women's health is very important to me. And to see the women's
clinic there have only not even a nurse practitioner.
It is not to say that the nurse there was not a competent
nurse. Probably is a very competent nurse. But that nurse
needed supervision if you are providing birth control pills,
are you going to be able to take care of someone if they have
phlebitis, a pulmonary embolus, and so on. So just a comment.
Dr. Hollenbeck. That was a nurse practitioner under the
grandfathering of VA rules, but she did not ever have a license
as a nurse practitioner. And you are absolutely right. She ran
the women's clinic forever and she still does alone. There is
no doctor fully overseeing her.
Mr. Roe. I yield back.
Mr. Coffman. Thank you, Dr. Roe.
Mr. Walz passes. Mr. Thompson.
Mr. Thompson. Thank you, Mr. Chair.
Just for the record, I would like to indicate that I have
toured the hospital there in Jackson on a number of occasions.
And, actually, Mr. Jenkins and I and others there have had
significant conversation. There is a history at this hospital
of not following VA procedure.
What I have been led to believe is since new administration
has come some of the things have gotten better, but nonetheless
it should not have gotten to the point that it did.
And the over-reliance on nurse practitioners rather than
doctors and writing of prescriptions by people unauthorized to
do it, those kind of things are most egregious in my review.
And I would hope that this hearing will put some of those
issues to rest, that they have corrected some of them. There
are some issues around patient management and other things that
I would like to hear, too, but nonetheless I appreciate the
opportunity to sit in on the hearing today.
Thank you.
Mr. Coffman. Thank you, Mr. Thompson.
Mr. Harper, further questions?
Mr. Harper. Thank you, Mr. Chairman.
I, too, have had the opportunity to tour the VA medical
center and I certainly have been much more impressed with at
least the opportunity to visit with Joe Battle. And the comment
was just made that some things are better. Other things are not
taken care of.
Would you agree with that, and I will ask each of you? Let
me ask this. Is there anything that is better that you are
aware of?
Dr. Hollenbeck. Not in primary care.
Mr. Harper. Okay.
Dr. Hollenbeck. And not----
Mr. Harper. And may I----
Dr. Hollenbeck. --in having permanent--there is no true
team in place.
Mr. Harper. And may I ask this of you, Dr. Hollenbeck? The
shortage of primary care physicians is not just a VA problem.
It is not just unique to the VA. It is a problem that we see
around the country.
But specifically for the VA, if you could map out any type
of strategy or plan, what would you do to attract primary care
physicians to the VA medical center in Jackson? What could you
do to do that? What would you do if you could call the shots?
Dr. Hollenbeck. Well, I would clean house from the top down
and I do think from VISN down. And then the medical center
trains physicians. It trains primary care physicians in family
medicine and internal medicine.
Now, some people are going on to subspecialties, no
question.
Mr. Harper. Right.
Dr. Hollenbeck. But if you showed that the people in
charge, the director of primary care was somebody they
respected, who wanted to have true teaching go on there, you
would have a supply of physicians and you could show that as a
place that people who are in the VA system and may want to
move, you could come to Jackson and there is an excellent
department because the wheel has been invented how to run
primary care.
Mr. Harper. Dr. Sherwood.
Dr. Sherwood. Let me just add that the director and the
VISN director have the authority to offer retention bonuses and
recruitment bonuses on top of the salaries of these direct
patient care providers. To my knowledge, it is not being used.
We have seen where apparently it is being used for the
senior executive service on a regular basis is the impression I
have been given. It certainly could be given if you want to
attract direct patient caregivers, they could use that
authority.
Mr. Harper. Give me a number. If you had the ideal number
of additional primary care physicians that the Jackson VA
Medical Center needs, how many would that be ballpark?
Dr. Sherwood. It is above my pay grade. Ask Dr. Hollenbeck.
Mr. Harper. All right.
Dr. Hollenbeck. Well, you have four clinics and I would
like to see actually four to five physicians in every clinic.
Mr. Harper. Additional than what exists?
Dr. Hollenbeck. Well, there is a few more. I think there is
five to six, although we still have temporary physicians coming
and going. But I think it should be primary care teams and then
all nurse practitioners assigned with a physician and strict
protocols.
Mr. Harper. For direct oversight?
Dr. Hollenbeck. Directly assigned, right.
Mr. Harper. General Hearon, you attended the hearing in
Pittsburgh that Chairman Miller conducted there and primarily
it was obviously not about the Mississippi VA system, but it
was mentioned. And so I know the Jackson VA Medical Center was
mentioned in that hearing.
Have you seen any improvements or anything that has taken
place that you have seen in a positive light since that hearing
that you attended?
Major General *Hearon.* Well, that was September the 9th, I
think. Dr. Hollenbeck did a fine job of testifying. I was there
for moral support, I guess, and to observe the audience. Dr.
Petzel who I was pleased to see is retiring next year, I made
an offer to help him pack.
But in any event, he was there and made a similar showing
in Pittsburgh I would say to what he demonstrated in Jackson on
April the 3rd at that town hall meeting which I provided a
video of to the committee, two copies in case you all did not
have it.
But I have not noticed and, of course, in government terms,
it has only been two and a half months. I think Mr. Battle's
heart is in the right place, but I do not think he gets the
kind of support both by his staff who I think try to keep him
in the dark on many issues, but at least they have for sure,
and I do not know if he has turned that corner or not, but from
above.
And I think just like in the military, I am convinced that
the clearest leadership should be coming from the secretary and
it is not.
Mr. Harper. I thank each of you for being here and I yield
back.
Major General *Hearon.* Thank you.
Mr. Harper. Mr. Chairman, thank you.
Mr. Coffman. Thank you, Mr. Harper.
Our thanks to the panel. You are now excused. Thank you
very much for your testimony today.
Our second panel, we will hear from Mrs. Rica Lewis-Payton,
network director of VISN 16. She is accompanied by Dr. Gregg
Parker, neurologist and chief medical officer of VISN 16, and
Mr. Joe Battle, director of Jackson VA Medical Center.
The complete written testimony will be made part of the
hearing record.
Ms. Lewis-Payton, you are now recognized for five minutes.
STATEMENT OF MS. RICA LEWIS-PAYTON
Ms. Lewis-Payton. Chairman Coffman, members of the
committee, and other members in attendance today, I am very
pleased to see our congressional delegation from Mississippi,
thank you for the opportunity to participate in this oversight
hearing and to discuss the policies and response of the
Department of Veterans Affairs in the wake of allegations
concerning the G.V. (Sonny) Montgomery VA Medical Center in
Jackson, Mississippi.
I am accompanied today by Dr. Gregg Parker, Chief Medical
Officer for the South Central VA Healthcare Network; and Mr.
Joe Battle, Director of the G.V. (Sonny) Montgomery VA Medical
Center.
The Department of Veterans Affairs and the Jackson VA
Medical Center are committed to consistently providing the high
quality care our veterans have earned and deserve. In
delivering the best possible care to our veterans one of our
most important priorities is to keep veterans safe from harm
while receiving care in our facilities. I, too, knew Mr. Johnny
Lee and was saddened by his death. I am deeply saddened by any
adverse event a veteran experiences while in or as a result of
care at the Jackson VA or any medical center.
I am proud of the hardworking and dedicated employees at
the medical center that are committed to delivering on
President Lincoln's promise. I was there when the medical
center was named for Mr. Veteran, Congressman Sonny Montgomery.
I understood then, as I clearly understand now, there is no
more noble mission than serving the men and women that stood
and took the oath to protect this country and the freedoms we
hold so dear.
The Jackson VA has a history of exemplary performance. The
medical center is at or above target on many performance
metrics and was recognized by the joint commission as among top
performing medical centers in this country on cardiac care. We
are rebuilding the executive leadership team and have had an
associate director and assistant director, and are currently
recruiting a chief of staff. Other key leadership positions,
such as chief of surgery, chief of pharmacy, and women veterans
health director have been recently filled.
Over the last year several veterans center care projects
have been completed, including construction of the mental
health unit, renovations to the oncology unit, the surgical
intensive care unit, and the women veterans clinic. We look
forward to completing more renovation projects for more private
rooms, as well as the community living center addition.
Compensation and pension exam times have improved from over
30 days in fiscal year 2012 to 14 days in fiscal year 2013. Our
vigorous homeless veterans program has housed 242 veterans in
Mississippi and provided valuable medical care and employment
counseling.
Shortly after his arrival Mr. Battle developed a plan to
transform Jackson's nurse practitioner driven primary care
model to one with an equal number of physicians and nurse
practitioners for its 20 medical center based primary care
teams. I am extremely pleased to announce that nine of the ten
physicians for primary care are on duty and the tenth is
completing the credentialing and privileging process. In
response to concerns at Jackson consultative program reviews,
site visits, and external surveys, including unannounced visits
from the joint commission, Office of the Inspector General,
Office of the Medical Inspector, and the Occupational Safety
and Health Administration have been completed.
Jackson continues to be accredited by the appropriate
oversight agencies, including Joint Commission, and has
developed robust action plans to address our recommendations.
Actions are being closely monitored to ensure completion.
So far I have provided information regarding what we are
doing at the Jackson VA Medical Center as a system. Please be
assured we understand that it is also about individual veterans
getting the healthcare they need when they need it. Our goal is
that each veteran will have an exceptional experience every
time they enter our facility. They deserve no less. We are
striving everyday to achieve this goal. When we do not achieve
this goal we reach out to those veterans and their families in
an effort to make it right for them and to improve our systems
and processes for other veterans.
Various allegations have been thoroughly investigated. We
are working aggressively to identify and correct errors and we
are adopting a series of reforms to improve. When appropriate
to do so we hold people accountable. Because this is an open
hearing with members of the public present, by law I am not at
liberty to provide specifics about what has been done in
individual cases. I welcome the opportunity to discuss details
in a private setting with congressional members as allowed by
law.
Mr. Chairman, we appreciate your interest in identifying
and resolving challenges at the G.V. (Sonny) Montgomery VA
Medical Center. I feel a great sense of duty to the men and
women who have served, and our efforts to improve will
continue. I thank you for the opportunity to appear before you
today and my colleagues and I are prepared to respond to your
questions.
[THE PREPARED STATEMENT OF RICA LEWIS-PAYTON]
Chairman Coffman, Members of the Committee, and other
Members in attendance today, thank you for the opportunity to
participate in this oversight hearing and to discuss the
policies and response of the Department of Veterans Affairs
(VA) in the wake of allegations concerning the G.V. (Sonny)
Montgomery VA Medical Center (hereafter Jackson VA Medical
Center) in Jackson, Mississippi. I am accompanied today by Dr.
Gregg Parker, Chief Medical Officer for the South Central VA
Health Care Network, and Mr. Joe Battle, Medical Center
Director of the G.V. (Sonny) Montgomery VA Medical Center.
VA and the Jackson VA Medical Center are committed to
consistently providing the high quality care our Veterans have
earned and deserve. In delivering the best possible care to our
patients, one of Jackson VA Medical Center's most important
priorities is to keep our patients safe from harm during their
time at our facility. I am saddened by any adverse consequence
that a Veteran might experience while in or as a result of care
at the Jackson VA Medical Center.
Let me discuss recent events at the Jackson VA Medical
Center and what we are doing in response. Be assured that we
have thoroughly investigated various allegations. We know that
a number of issues have been raised about this Center, and we
take those concerns seriously. We work aggressively to identify
and correct any errors, and we are adopting a series of
significant reforms to improve the center. When appropriate to
do so, we hold people accountable. Because this is an open
hearing, with members of the public present, by law I am not at
liberty to provide specifics about what has been done in
individual cases.
On March 18, 2013, the Office of Special Counsel (OSC) sent
a letter stating that OSC had found a pattern of issues at the
Jackson VA Medical Center that are indicative of poor
management and failed oversight. The letter cited five separate
complaints received from facility employees since 2009.
Three of the complaints concerned allegations relating to
the Sterile Processing Department. The letter alleged that poor
sterilization procedures existed; that VA made public
statements mischaracterizing previous investigative findings
about the facility's sterilization procedures; and that VA had
failed to properly oversee corrective measures within the
Sterile Processing Department. The letter also cited complaints
alleging chronic understaffing of physicians in primary care
clinics; lack of proper certification for nurse practitioners;
improper nurse practitioner prescribing practices for
narcotics; and missed diagnoses and poor management by the
Radiology Department. All of these complaints were referred to
VA for investigation pursuant to 5 U.S.C. Sec. 1213.
At the time the March 18th letter was received, VA had
appropriately responded and corrected the issues cited in the
three whistleblower allegations related to the Sterile
Processing Department.. These issues are all closed. , Jackson
VA Medical Center has implemented stringent oversight processes
to ensure reusable medical equipment is cleaned and sterilized
according to manufacturers' instructions before every use. The
facility has also invested more than a million dollars into
state-of-the-art reprocessing equipment to ensure proper
cleaning and sterilization and transitioned to the use of more
disposable devices when these are available. After receiving
the March 18th letter, VA initiated a quality of care review of
sterile processing services at the facility. The review found
that the VAMC utilizes effective systematic processes to safely
perform the re-processing of all critical and semi-critical
reusable medical equipment in the facility. The Jackson VA
Medical Center continues to monitor and evaluate the Sterile
Processing services.
The other two complaints discussed in the March 18th OSC
letter had been referred to VA on February 29 and March 5,
2013. The February 29th complaint involved the Primary Care
Unit at the Jackson VA Medical Center, and the March 5th
complaint contained allegations concerning the accuracy of
certain interpretations by a VA radiologist who is no longer a
VA employee. In response to these OSC referrals, a review team
outside the Veterans Integrated Service Network (VISN),
chartered by the Deputy Under Secretary for Health for
Operations and Management (DUSHOM), conducted a full
investigation of the two new cases.
VA's reports on these two investigations were delivered to
OSC on July 16 and July 29, 2013. The OSC sent a follow-up
letter, dated September 17, 2013, concerning those reports.
Therein, OSC reported the Department had substantiated some of
the whistleblowers' allegations and recommended follow-up
actions, but OSC indicated the status of the recommended
actions was unknown.
Efforts to implement the recommendations in VA's July 2013
reports are well underway by the facility and the VISN, with
active monitoring by the Office of the Medical Inspector (OMI).
Specifically, in September 2013, the Under Secretary for Health
directed the OMI to oversee implementation of the action plan
at the Jackson VA Medical Center. OMI conducted a site visit on
October 22-23, 2013, and both reviewed and concurred with the
facility's action plan. OMI and the DUSHOM will continue to
monitor implementation of the action plan and keep Veterans
Health Administration (VHA) leadership apprised of the progress
in implementing the reports' respective recommendations and the
sustainability of the recommendations. On May 24 and June 12,
2013, OSC referred two additional complaints to VA for
investigation. These referrals concerned pharmacy operations
and the credentialing and privileging processes at the Jackson
VA Medical Center. VA's report on the credentialing and
privileging matter was delivered to OSC on August 15, 2013. The
facility revised its credentialing and privileging processes to
ensure it is consistent with National VHA policy. The Jackson
VA Medical Center will ensure all members of its Executive
Committee of the Medical Staff have equal access to review all
credentialing and privileging folders prior to submitting its
recommendations to the Medical Center Director for approval.
The report concerning pharmacy operations was delivered to OSC
on August 27, 2013.
Jackson has undergone many consultative program reviews,
site visits, and external surveys, including recent unannounced
visits from The Joint Commission, the Inspector General, OMI,
and the Occupational Safety and Health Administration. Jackson
is accredited by all appropriate agencies, including The Joint
Commission. During the past 12 months, subject matter expert
teams have been deployed to conduct assessments of primary care
and assist in the development and implementation of actions to
address deficiencies. Additionally, staff from across the VISN
have been deployed to fill key leadership vacancies. These
activities are in addition to the standard annual reviews of
quality and safety, financial operations, and environment of
care.
On April 3, 2013, VHA hosted a town hall meeting in
downtown Jackson. The Under Secretary for Health was among the
speakers at the meeting, which was attended by nearly 300
Veterans, facility staff members, and other community partners.
During the town hall meeting, the participants discussed many
of the issues covered in the OSC letters and other issues of
concern to Veterans. Mr. Battle has personally addressed
participant comments provided on comment cards at the town hall
meeting and met with all interested parties who desired a
meeting with him as follow up.
Given the issues raised concerning the Jackson VA Medical
Center, I have provided intense oversight of facility
operations. This includes weekly calls with the Medical Center
Director, monthly operational calls with the Executive
Leadership team, and site visits to the facility to include all
employee town hall meetings.
Conclusion
Mr. Chairman, we appreciate your support and encouragement
in addressing issues at the Jackson VA Medical Center. VISN 16
and the Jackson VA Medical Center will continue to work hard
and improve the high quality of care to our Nation's Veterans.
Thank you for the opportunity to appear before you today, and
my colleagues and I are prepared to respond to any questions
you may have.
Mr. Coffman. Thank you, Ms. Lewis-Payton. Since the death
of Johnny Lee in April, 2011, what efforts have been taken to
improve supervision and personnel shortages to stop further
preventable deaths?
Ms. Lewis-Payton. Thank you, Mr. Chairman. I will tell you
that that death has saddened all of us. And therefore we had
thorough investigations by external review bodies to look at
the circumstances under that death and those investigations
were complete and actions taken as needed were completed as
well. We continue to provide oversight in terms of the care
that is provided at our facility. That oversight takes a number
of forms. There is a very robust performance management system
in the Department of Veterans Affairs. In addition to that the
VISN does site visits routinely at least on an annual basis. We
have the joint commission survey that has occurred. The Office
of the Inspector General also does a comprehensive assessment
program of the VA on a routine basis. So there are a number of
systems and processes in place to address it.
I must also say, sir, that despite our best efforts
healthcare is complex and errors will inevitably occur. But
what I can also tell you is when they do occur that we take the
actions to address those errors to make it right for veterans
and to improve our systems and processes for veterans in the
future.
Mr. Coffman. Thank you. Just a point, you had mentioned the
joint commission. You have referenced that and I want to remind
you that the joint commission does not investigate allegations
of negligence, they only assess compliance with their own
requirements. Also the FDA released a safety report in
February, 2011 warning of the bleeding risks associated with
wound vacs and advising of the need for frequent monitoring.
And as recently as September 17, 2013 the Office of the Special
Counsel wrote a 22-page letter to the President explaining how
VA was not taking adequate action to correct problems and not
taking these issues seriously at your facility.
Mr. Battle, Jackson has had other preventable deaths and
occurred recently. For instance, a patient in 2010 who suffered
a diabetic coma and died in the intensive care unit, and
another patient who died after having both legs amputated due
to the misdiagnosis of a protein deficiency. Will you provide
us with the records associated with these cases?
Mr. Battle. We will be happy to provide you records, sir.
Mr. Coffman. And when can you have those to us?
Mr. Battle. I will get those records to you within 30 days.
Mr. Coffman. Very well, thank you very much. Dr. Parker, it
was a uniform practice at Jackson to redirect veterans to
``vesting clinics'' that did not exist which resulted in double
booking and in many cases veterans being turned away without
care. What efforts if any have you taken to end this practice?
Dr. Parker. Thank you, Mr. Chairman. I had the privilege of
serving 28 years in the Navy uniform as a combat surgeon in two
war theaters. I use that experience to guide me as I provide
the oversight for the ten facilities in the VISN. That
experience alone does not allow me to by itself look at the
issues and address the concerns when they arise. I rely on data
and I rely on the data sources. But I personally receive all of
my care at the Jackson VA as a veteran. Since 2005 I have
received all of my primary care from a nurse practitioner----
Mr. Coffman. Can I go back to the question, please? Dr.
Parker, it was a uniform practice at Jackson to redirect
veterans to ``vesting clinics'' that did not exist which
resulted in double booking and in many cases veterans being
turned away without care. What efforts if any have been taken
to end this practice?
Dr. Parker. The primary care clinics at Jackson have
evolved and we have fully implemented PACT. In the VA terms
that is a patient aligned care team. That ensure----
Mr. Coffman. And when did you implement this?
Dr. Parker. It has been fully implemented in Jackson, which
was slow out of the gates, and fully implemented as of August
of this year where they met all of the metrics that we hold
them to.
So currently there are no vesting clinics. We expect that
the provider, nurse practitioner or physician, will manage
their panel of 1,200 patients at an average of about three
visits per year, because that is what the national average is.
So that practice----
Mr. Coffman. Were you aware of the vesting clinics?
Dr. Parker. I was not.
Mr. Coffman. But it was your responsibility to know, was it
not?
Dr. Parker. Yes.
Mr. Coffman. Very well. Sergeant Major Tim Walz, State of
Minnesota.
Mr. Walz. Thank you, Mr. Chairman. Thank you all for being
here today. And after listening to the first panel, and now
hearing this, and I want to say I am very appreciative of all
of your service. And Ms. Lewis-Payton, I am very appreciative
of the point you brought up on due process, and some of the
things that are there. But due process should never endanger
veterans. And I am fearful that we, at times there is a fine
line there. I hope we stay on the right side of what we are
willing to give and do but with the best interest. And I know
your hands are tied on certain legal matters.
But one of the things in this job I have had the privilege
and the responsibility of is visiting many different centers.
And they are all slightly different. The commitment of the
folks who are working there is never in question. But their
outcomes, like so many things, do vary. And I think after
listening, and I am going to hear some responses to some
specific questions, this one appears to me that there is a bit
of a cavalier attitude being put forward and I daresay almost
dismissive of the reports. Because there has been a paper trail
here and a review that has gone. The only other time I saw this
maybe at this level was in Miami and we have seen these things.
So I would ask you this. The concerns you heard brought up
from staffing to undue pressure being put on by two physicians,
how do you account for that? How do you account for that
pervasive and I would say cancerous attitude that was in
amongst some of the staff? And any of you can try this. And I
know, Mr. Battle, you have not been there a long time. But I
myself have seen these things as being cultural and they tend
to extend beyond directors at times. So let me.
Ms. Lewis-Payton. Yes, Mr. Congressman, thank you sir for
the question. Let me first say that I come to work every day
with a sense of duty and responsibility to the men and women
that we serve, and I am honored to do so. I take these
allegations and these concerns very seriously.
Major General Eric Hearon can tell you I have had numerous
conversations with him. When he brings those concerns, we may
disagree on the approach to address them but he cannot say that
I did not address them.
I will also say to you that I absolutely agree with you
that at no time can we as leaders put people, put veterans in
harm's way. So I can assure you, sir, that when there are, when
we have information to suggest that harm is being done to a
veterans, yes there are due process requirements that we are
obligated to complete. But what we do is to remove those
persons from that environment while we complete the
investigation----
Mr. Walz. Were all veterans notified as soon as you found
out on the misreadings on the radiological exams and things?
Were veterans notified in writing and given an opportunity?
Were they also told what their legal obligations were assuming
that there was negligence here, possibly bordering on criminal?
Were all those, was every veteran notified of their rights?
Ms. Lewis-Payton. Sir, there are some complex issues. And
so not all of the information that is currently in the public
domain is correct. So----
Mr. Walz. So it is possible that a veteran who was
misserved by this went home and still to this day does not know
that there was a problem and that they have some legal
recourses?
Ms. Lewis-Payton. I can tell you for those cases where it
was confirmed that an error was confirmed that caused harm to a
veteran, an institutional disclosure was done. And Dr. Parker
can speak more specifically to the systems and processes in
place associated with that and the radiology cases were
followed in that process too. There is some additional work
because of the concerns that have been expressed to go back and
take a second, a third, and even a fourth look. But I can
assure you when there is a confirmation that an error occurred
that caused harm to a veteran, an institutional disclosure
either has been done or will be done.
Mr. Walz. So the situation at Jackson, Dr. Parker in your
assessment, was just a couple of bad folks who just did not do
what they were supposed to do?
Dr. Parker. The individuals at Jackson that are practicing
there are all good individuals. They go there with the intent
to provide good care. There are on occasion some errors that
occur. I have not run across a provider yet who intended for
those errors to occur. But errors do occur. And when they----
Mr. Walz. That is the role of processes.
Dr. Parker. Correct.
Mr. Walz. Whether it is sterilization processes on medical
equipment, and to know that there is a checklist that you
follow, and then someone is in charge to make sure the
checklist was followed. Is that where the breakdown was?
Dr. Parker. Yes, in part. In part the processes needed to
evolve to keep up with the standard of care and the standard of
medicine. For example, sterile processing. You used to, when I
started practice back in the seventies and we used a scope,
which was a flexible scope, we wiped it down with alcohol. That
was the accepted standard then. Now it has to be, go through a
highly decontamination process----
Mr. Walz. I am very familiar with this issue----
Dr. Parker. Yes.
Mr. Walz. --because of the colonoscopy scopes. And I have
had them set in front of me on how we do it. The problem there
was we did not have a process in.
Dr. Parker. Correct.
Mr. Walz. It was instituted systemwide and since that time
for the most part we have reduced those errors. My question is
is that some of the policies that were not being followed in
Jackson were being followed in other places where they did not
have this process occur. And that to me seems to be the
critical issue, of who is responsible for making sure that
those things happen. And I have gone over my time. I appreciate
the chairman's indulgence. We will come back around. Thank you.
Mr. Coffman. Let me just say quickly, Ms. Lewis-Payton,
that this report by OSC to the President of the United States
on September 17th contradicts your testimony today and states
that you are not serious on the date of this report and prior
in terms of addressing these issues. Mr. Palazzo?
Mr. Palazzo. Thank you, Mr. Chairman. I appreciate you
letting me join this important hearing today, especially for
the second panel. And it is fitting just a few days after
Veterans Day that we are having this hearing. And before I
begin I want to note that this hearing has a special meaning
for me since we are specifically discussing the Sonny
Montgomery VA Medical Center. Many of us in Mississippi and
around the nation remember very clearly the work Sonny
Montgomery did on behalf of our nation's veterans. So it is
heartbreaking and quite frankly makes me angry that the VA has
so completely screwed up a medical center with the name of such
a great supporter of our veterans. In fact, it is disgusting.
Now I am not on the VA Committee but I am a veteran.
Veterans have to wait more than a year to receive benefits and
when they do it is painstakingly problematic. Now I have had my
issues with the VA Medical Center in Biloxi and we are working
through those. I have been assured those issues are going to be
handled. But the complaints keep coming in. My office is
regularly called upon to interface on simple yet frustrating
matters for veterans. Some examples include failure to give
proper notice of appointments causing scheduling difficulties
for aging veterans; veterans being turned into collection
agencies due to billing errors by the medical center;
unnecessary hurdles to fill regular prescriptions; and long,
excruciating, all day waits at the medical center only to find
out you are waiting to see a nurse practitioner and not a
doctor.
And now we have these stories from our veterans coming out
of Jackson. Those that we have heard this morning, those from
my constituents from across the State of Mississippi. While I
am thankful that my office has not experienced a tragedy like
the incident of Mr. Lee, a VA employee and Army veteran, I must
ask why does a veteran have to call their congressman for
assistance on what should be routine matters performed by the
medical center? If you cannot get the simple matters right it
strikes utter fear in me when I hear the horror stories
described earlier.
I am appalled because our veterans deserve better. These
men and women fought for our country, came back, and they
deserve better. They deserve better from a Veterans
Administration that for years has said do not worry, we will
fix it. Do not worry, we will fix the claims backlog. Give us a
little more time and we will fix the problems at our medical
centers. Provide a little more funding, and it will all be
okay. Well guess what? It is not okay, and it has never been
okay. It is a problem from the top down.
But I want to focus briefly on those of you here before us
today. Veterans are literally dying at the Jackson VA because
the VA cannot fix their problems. I mean, those reports I am
reading are sickening. Veterans left to die because they were
forgotten about. Bad prescriptions, illegal prescriptions,
patient overbooking, the list goes on. So I want to know on
behalf of the veterans of Mississippi, Mr. Battle, what are you
doing to personally fix these issues? And what are you going to
do? What are you doing now, what are you going to do? And I do
not want to hear political jargon. I want to hear you tell this
committee, tell me, and tell the State of Mississippi, what are
you doing to fix these problems that are facing our veterans?
Mr. Battle. Well thank you, Congressman Palazzo, for your
question. I appreciate the opportunity to speak before the
committee today. More specifically to your question, sir, you
mentioned benefits to start with I think. One of the things
that I have done in Jackson and continue to focus on is
processing medical evaluations for veterans. When I got to
Jackson the average processing time was a little over 30 days,
the standard for VA was 30. Today we are processing in the 14-
to 15-day range on average. So we have cut that in half and,
you know, we are very happy that we are able to do that so when
the claims do come to us we turn them quickly.
MR. *Palazzo.* Let me, I appreciate that, and I do not mean
to interrupt. I have just got a few more questions. How does it
feel to know that your colleagues, they were not terminated,
they were not fired for their gross incompetence and possibly
illegal behavior? That they are still amongst your ranks in the
VA system? Does that make you proud of the service that you do?
And I do not, I hope that I am not overstepping. But I know if
I worked a career in the industry, and I know you all have
sacrificed for our veterans, and you are here, you are not 100
percent responsible. And I know you have good employees. Mr.
Jenkins mentioned that you have good rank and file employees.
You have got good doctors at the VA medical system. But does
that make you all proud? That the system that you have grown up
in is just transferring people from one place to another? Mr.
Battle, let us start with you.
Mr. Battle. Well thank you for the question, Mr.
Congressman. I have over 30 years of service with the VA and I
am very proud of that service. And it has been my life and my
passion. And it continues to be today and it is everyday that I
get up, because I do not think there is any greater job to have
in the United States than to take care of our nation's
veterans. And any time that we have an incident or something
occur, where something did not go like it should, that takes a
little bit out of me and it is my job to make it better. And
that is what I concentrate on each and everyday when I go to
the office.
MR. *Palazzo.* Mr. Battle, my time is up. And I hope you
are the last director in Jackson for a long time and that you
personally oversee fixing the problems and paying for the
mistakes that have been made, especially to the veterans. I
think they need to be immediately notified of the possibility
that their results were erroneous, or were not read at all. And
I appreciate your passion. Because I know for a fact, my wife
started out in the VA medical system in Houston, she worked in
the VA medical system until Hurricane Katrina took that, pretty
much that whole facility. So I understand. And sir, thank you
for your service. And Ms. Payton, I thank you for yours. But
please do not every write this off, or call this kerfuffles. I
am with Chairman Coffman. If you use a word like that in the
military, you are probably not in the military, you are just
passing through. But please, do not dismiss this. Work hard.
Make us proud. And most of all, let us make Sonny Montgomery
proud. Because wherever he is, he is looking down, he had got a
heavy heart.
Mr. Battle. Yes.
MR. *Palazzo.* So we owe it to him, but we owe it to the
veterans. That is the first and foremost, number one priority.
Thank you, Mr. Chairman.
Mr. Coffman. Thank you, Mr. Palazzo. Mr. Thompson of
Mississippi?
Mr. Thompson. Thank you very much. Ms. Payton, when, if you
have the information, can you provide this committee with a
timeline from the notice of Mr. Lee's death to how it was
investigated? You know, the question I think in a lot of our
minds is it was not taken seriously. And I think the timeline
can clear up a lot of that.
I guess the other question in light of some of what I heard
earlier is what part of the system failed the veterans in
Jackson so that so many of these errors kept occurring and
reoccurring? It appears that some standard of checks and
balances just was not adhered to, and were being overlooked.
Can you shed some light on that?
Ms. Lewis-Payton. Yes, sir. Healthcare as you all know if a
very complex operation. And when I look at my network as an
example, which includes ten VA medical centers, 60 community-
based outpatient clinics, in all or part of eight states,
20,000 employees. At the Jackson VA Medical, Mr. Battle can
quote the specific number, 1,500 employees. You have a large
number of outpatient clinics. A lot of opportunities in a large
complex system for errors to occur.
When you say that there are systemic issues clearly over
the last several years there have been significant concerns and
media attention surrounding the Jackson VA Medical Center. What
I can tell you today, and this has been the case since I
arrived at this position, as was mentioned before I also knew
Sonny Montgomery. And the naming of that facility, that you
have my commitment, ongoing commitment to address the issues
and to make that facility better. And that is what I work on
each and every day and will continue to do so.
Mr. Thompson. And there is no question about it. But I
think some of us are concerned that the culture of the facility
allowed certain things to go on that those situations are
inconsistent with good medical practice. And I just, I want----
Ms. Lewis-Payton. There is no question that organizational
climate and culture makes a difference. As was mentioned, we
have had a significant turnover in the leadership positions at
Jackson and we are rebuilding that facility from its foundation
up.
Mr. Thompson. Well----
Ms. Lewis-Payton. It has taken us some time to fill those
vacancies.
Mr. Thompson. Well----
Ms. Lewis-Payton. Because we want to make sure that we have
individuals that like Joe and I, and Dr. Parker, are also
committed to making it better.
Mr. Thompson. Right. Right. Well you know, I toured the
facility last June, and I have been up a couple of other times.
But the OSC letter causes me great concern. Because some of
those things we talked about a year and a half ago have been
brought up in this letter. And what prevents you from fixing a
problem when you find it?
Ms. Lewis-Payton. Sir, I would say that we are addressing
the issues. And I agree that the complaints in the OSC letter,
they are those complaints from 2003 and 2007. The primary care
complaint is different. But those are the same complaints. If
you look at the supply processing, for example, there have been
subsequent reviews and significant investment in that area
since 2010.
Mr. Thompson. Right. I----
Ms. Lewis-Payton. And that complaint has been----
Mr. Thompson. Well if it has been ongoing I think some of
us are saying what stops the complaints from being fixed? If
you have been rolling them for ten years, that is a problem.
And I think you are aware that OSC disagrees with your
response?
Ms. Lewis-Payton. Yes, sir.
Mr. Thompson. And you are preparing a response to them?
Ms. Lewis-Payton. Yes, sir.
Mr. Thompson. Has a peer review been conducted by Dr. Khan
in Dr. Khan's case?
Ms. Lewis-Payton. There have been several. Dr. Parker, do
you want to speak?
Dr. Parker. In the 2007 time frame there were several peer
reviews that were conducted for Dr. Khan. What you are
referring to now is the Office of Special Counsel and some
requirement or mandate to review more of his films. That is
under review at the highest level here at the VA and the
response will be afforded to Office of Special Counsel.
Mr. Thompson. There is a 60-day turn around on a response
to the OSC report. You have got to be pretty close to it now.
Do you know when it will----
Ms. Lewis-Payton. Yes, sir. It is my understanding that it
was submitted today. But since that is an active and ongoing
issue with VA and OSC we are not at liberty to discuss it here.
Mr. Thompson. Thank you.
Mr. Coffman. Thank you, Mr. Thompson. Dr. Benishek, State
of Michigan?
Mr. Benishek. Thank you, Mr. Chairman. Dr. Parker, this guy
that had these problems with the radiology reviews, you have
not reviewed his films that he did then? I mean, you are
planning on doing that?
Dr. Parker. There are two issues there, Dr. Benishek. One
of them has to do with the 52 cases that were talked about in
the testimony here, and the other has to do with a request to
review more films of Dr. Khan that were read from 2003 to 2007.
The 52 films, actually there are 58 cases at this point, that
have been thoroughly reviewed by at least three external
reviewers all to substantiate whatever the claims were. And
that has gone to the Office of the Medical Inspector last week
so that they can finally bring to closure any concerns about
those 52 cases, we think there are 58 that we will need to
review. The other issue has to do with a peer review of X
number of charts from Dr. Khan.
Mr. Benishek. The other question I had is, I had mentioned
it earlier, you may have been here for that, you know, the
Morbidity and Mortality Review Panel within, you know, each
medical center.
Dr. Parker. Right.
Mr. Benishek. You know, I am very familiar with that.
Because you have to get up there and, you know, tell about your
failures. So you are the Medical Director for the VISN, right?
Or the Chief Medical Officer?
Dr. Parker. Yes, sir.
Mr. Benishek. So then are you involved in making sure that
kind of happens throughout your VISN?
Dr. Parker. Yes, sir. There are several places where that
can occur, several places where it must occur. You are, as a
surgeon, familiar with the Morbidity and Mortality Conferences.
And that is a very lively discussion among surgeons and others.
Each facility is expected to do that, although it is not
technically a requirement. There is also a peer review
committee where everything must be reviewed that hits a certain
category. When untoward events happen, you know, hospitals take
care of disease and unfortunately there are patients that die.
That is expected on occasions and unexpected on others. Every
one of those get reviewed at the facility and it forwards up to
me, usually in an institutional brief or an issue brief so that
I can see it. It comes up in a different way for any cases that
were seemed to be outside the norm, where there should be
disclosure. I review every single one of those.
Mr. Benishek. Let me ask a question about the organization
of the clinics and that, because I know in my experience and in
my Subcommittee on Health in the VA Committee, you know, we are
concerned about, you know, physicians not having the input to
manage the clinics and that they end up being sort of the
worker bees, and then the nurses or the administration is sort
of managing the clinic. And we have run into circumstances
where physicians end up doing their own blood pressures and,
you know, wasting physician time. Can you expand on that? Is it
completely separate from the physicians? I mean, is the Chief
Medical Officer organized a clinic, or is there a chief of
staff in each individual hospital? Or do they just sort of go
to their assignments?
Dr. Parker. As a clinician, there are two basic models. One
is the product line and one is a non-product line, if you will.
But as a clinician I always took the responsibility myself. You
know, I was responsible for the patients. In the primary care
arena, the PACT teams, the patient aligned care teams, are
specifically designed to do exactly what you say. There are
supposed to be three support staff for each provider. That
provider and those support staff, which is----
Mr. Benishek. So but does the physician have the
determining, I mean, who determines how that all works? Is it
the administrator? Is it the director of nursing? Or is it the
medical staff----
Dr. Parker. It should be the service chief, sir. They are
they, healthcare is delivered one on one, face to face. And the
service chief, which is the Chief of Ambulatory Care, or the
Chief of Primary Care, or the Chief of Surgery----
Mr. Benishek. A physician?
Dr. Parker. A physician.
Mr. Benishek. That is the complaint I hear most often
amongst VA physicians, is that, you know, the way the thing is
managed is not to their liking and they seem to have little
input.
Dr. Parker. Well and I will say, as a physician I think I
can say this, all physicians are not great managers and they
need the assistance of other professionals. It should be a
team. But----
Mr. Benishek. Well absolutely. I understand there is other
input there. Because I know when I had my own practice, you
know, I tended to want to manage it most efficiently for my
time, for my patients' time----
Dr. Parker. Right.
Mr. Benishek.--but sometimes when you get to the, you know,
the VA, I did not have much input as to how my clinic was run.
You know, being a fee for service physician coming in on a----
Dr. Parker. Yes, sir.
Mr. Benishek. --whatever day it was. Sometimes we could
have improved it if we could allow more patients to get in
there, to make effective use of staff and the patient time. And
I just get kind of concerned over many of the situations that
we heard here, you know, the most egregious was, you know, a
ghost clinic, where people were coming into a clinic and there
was nobody staffing it. I mean, it is pretty shocking to have
heard that that went on.
Dr. Parker. Yes, sir.
Mr. Benishek. How can we fix this, Dr. Parker? I mean, how
do we instill the need or the management goal of having good
patient care rather than, it seems to me that these guys were
motivated by having to produce some statistic.
Dr. Parker. Yes, sir. I think when I was in the military
for 25 years the military had a nice cessation planning and a
gradual progression of responsibilities and you learned it. I
think what the VA lacks in comparison is that progression. We
promote leaders into positions without the support, without the
education, without the training, without the structure that
would allow them to be successful. In particular for
physicians. I mean, the training piece of it is phenomenally
detailed, as Ms. Payton says, it is a very complex system. I
think that we provide a disservice for our providers and our
service chiefs, and I am not talking just physicians here, that
we should have better mechanisms to train them.
I recently started my own training for the chiefs of staff
because, in part because of Jackson. There is a phenomenal
amount of responsibility and accountability and things that you
must understand, credentialing, privileging, to get it done. So
we now have a once a quarter, face to face, that is about a day
and a half or two days. That is about all we can package
together, especially for the travel requirements right now. But
personally have put that together and trained the chiefs of
staff so that they understand the responsibility. And hopefully
that will go down to the service chiefs level.
Mr. Benishek. So there is no general VA system for that to
be done? You just had to institute it on your own, basically?
Dr. Parker. Correct.
Mr. Benishek. All right. Thank you. Sorry I am overtime.
Mr. Coffman. Thank you, Dr. Benishek. Mr. Harper of
Mississippi.
Mr. Harper. Thank you, Mr. Chairman. And I thank each of
you for being here. And it is good to see some of you again.
And I do want to say, Mr. Battle, I appreciate your hospitality
on the occasions we have had to visit. I know there is a lot
that has been done, but still it appears there is a lot that
still needs to be done. And we want to make sure that we equip
you to make sure they are done, keeping in mind that patient
care is paramount at the VA. And the commitment that we have to
our veterans is just critical. And that we do not ever want to
look like we are not fulfilling that.
Now one thing that I had, was concerned about is we have
obviously in the, among our patients at the VA, we have a lot
that need orthopaedic care. Do we have any orthopaedic surgeons
on staff currently?
Mr. Battle. Yes, sir. We have one orthopaedic surgeon on
staff today.
Mr. Harper. How can one orthopaedic surgeon, I assume it is
a full time position?
Mr. Battle. It is full time.
Mr. Harper. How can one orthopaedic surgeon take care of
all the orthopaedic needs in our VA patient population at the
Jackson VA Medical Center?
Mr. Battle. Well thank you for the question, Congressman
Harper. One cannot. And normally we would have three. And we
lost two of our orthopaedic surgeons last fall. We have been
aggressively looking to recruit new ones.
Mr. Harper. So that has been a year ago? Fall, so we are a
year?
Mr. Battle. November, yes, sir.
Mr. Harper. Okay, sorry.
Mr. Battle. And as you know, Mississippi is a medically
underserved state and recruiting physicians is difficult. But
we want to make sure that who we hire is someone who can be
collaborative with the University, our medical affiliate next
door, ourselves, and take care of our veterans the way we want
them done.
In the meantime what happens is we feed (use of Non-VA
care) those cases out to the community, is how we handle it
presently.
Mr. Harper. I have been told by some that getting outside
orthopaedic care is difficult because of the delay in payment
from the VA. Is that accurate or not?
Ms. Lewis-Payton. We have certainly had some challenges in
that regard. And we are working very closely with our vendors
in order to continue to provide that care. In addition we have
instituted a number of actions to address our fee processing
times. These are not simple things, as I mentioned. Our network
is ten VA medical centers across eight states. And our fee unit
is centralized. So that is a lot of claims going through a
system. We are improving our IT infrastructure, going to two
shifts, and doing some other things to increase that.
The other thing I will mention as it relates to recruitment
of specialty physicians, particularly in Mississippi that is
underserved. And Dr. Sherwood mentioned it, we are using all of
the recruitment and retention incentives available to us in
order to attract. But it is a challenge.
Mr. Harper. All right. Let me ask both of you right now. We
have been basically, I assume, one orthopaedic surgeon for
almost a year, or approximately a year. What kind of time frame
are we on? When will we see that in house, where we will have
three? Do we have any leads?
Mr. Battle. Yes sir, we do. We are vetting two candidates
right now.
Mr. Harper. Okay, thank you. Dr. Parker, if I may ask you
Linda Watson was the subject of a 2006 OIG report that found
she misused funds, did not cooperate with investigations, and
created a very, for lack of a better word, a very stressful
environment during her role as the VISN 7 Director. So why was
she hired as the Director of the Jackson VA Medical Center
after that?
Dr. Parker. Thank you, sir. I am not sure if I can answer
your question completely. She was transferred to the VISN 17
staff in Dallas, Texas, and after a period of time was moved to
the Jackson VA as the Medical Center Director.
Mr. Harper. Well how do we make sure that our future
problem children are not just moved to another location? I
mean, this is a problem that we have got to address and we have
got to stop. And that is we cannot continue to reward bad
behavior. So what is the answer there, Ms. Lewis-Payton?
Ms. Lewis-Payton. Sir, I would agree with you. And what I
will also tell you is one of the things about this wonderful
country that we live in is that people get due process and all
of those sorts of things come into play as well. So when there
are findings as you know all of that is assessed relative to
the overall performance of a person, and then there are
decisions about what actions there are to be taken associated
with that. And all I can tell you is that I am sure that that
process was followed as it relates to the person you mentioned.
Mr. Harper. Well then the process needs to be changed. So
thank you very much. I appreciate your time. I yield back.
Mr. Coffman. And we will do a second and final round for
those members that have questions. Ms. Lewis-Payton, why is VHA
now pushing to amend its nursing handbook? Does that designate
an nurse practitioners as independent practitioners without
regard to state licensing restrictions?
Ms. Lewis-Payton. Sir, as you may be aware VA does follow
the state requirements as it relates to licensure. The thing
that is different about perhaps the VA is that a person can
have a license in any state and then be able to practice at a
VA facility. But the full requirements associated with that
state, those are, those are followed.
As was previously mentioned by one of the congressional
members of this committee, a physician, that in this country
there are areas where we have, we have underserved areas where
it is difficult to recruit physicians, particularly specialist
physicians. And so nurse practitioners are used as physician
extenders, if you will. But the oversight responsibility is
still there in terms of collaborative agreements and those
sorts of things associated with it.
As it relates to specific questions about the VA's policy
in pursuit of a certain policy, I am not in a position to
answer that.
Mr. Coffman. All right. Well let me remind you that on June
21st VHA recommended that Jackson leadership should stop
designating nurse practitioners as licensed independent
practitioners unless their licensing state permitted them to do
so. So let me leave you with that.
Mr. Battle, how many different people have served as Acting
Chief of Primary Care in the last year?
Mr. Battle. In the past year? Three.
Mr. Coffman. I think Dr. Hollenbeck in her testimony stated
that there has been one every three months since March, 2013.
Would you say that that is a very high turnover rate?
Mr. Battle. Well we have acting associate chiefs of staff
for primary care, sir, as we are searching for a new permanent
Associate Chief of Staff for Primary Care. And we have brought
one person in from detail. We had one person within house do
it. And now we have another person from in house acting as we
continue that search.
Mr. Coffman. Ms. Lewis-Payton, in 2012 you received a bonus
of $35,940. Why was this information not included on the
disclosure from VA to this subcommittee with the rest of the
2012 bonuses?
Ms. Lewis-Payton. Sir, I am not aware that it was not
included. It is a matter of public record.
Mr. Coffman. Thank you. Mr. Walz from Minnesota? Passes.
Mr. Thompson?
Mr. Thompson. Thank you. I think I am concerned with how we
are presently handling situations, too. Mr. Battle, Mr. Jenkins
mentioned that a number of patients have fallen in the month of
September. Are you aware of that?
Mr. Battle. Yes, sir. I get a report on falls. And I am
aware that there has been some falls and we have a group
looking into that.
Mr. Thompson. So is 14 people in the month of September
considered a high number? About average? Or what?
Mr. Battle. I think it depends on where the falls are, sir,
and as to whether it is a high number or not. Let me just say
that I consider falls an important issue that we are looking at
and we want to make sure whenever possible that no veteran
would fall in our care.
Mr. Thompson. So are you looking into the fall? Are you
looking into whether or not is a shortage of nursing, or
support personnel for the patients?
Mr. Battle. Yes, sir. We look at all of it. We look at when
the falls occur, what the staffing ratios are, and for any
other causal factors that may have been contributory to them.
Mr. Thompson. Thank you. Mr. Jenkins also referenced the
practice of nepotism, and managers hiring family members into
nursing positions. Are you aware of that?
Mr. Battle. Yes, sir, I am aware of his allegations in that
regard.
Mr. Thompson. Are you looking into it? Or have you looked
into it?
Mr. Battle. Yes, sir. In regards to the Nurse Executive,
there are administrative activities going on.
Mr. Thompson. So it did happen?
Mr. Battle. I am not at liberty to discuss it because it is
an ongoing personnel issue, sure.
Mr. Thompson. So--okay. But it is against VA regulations to
hire a relative at a certain relationship?
Mr. Battle. Under VA regulations it depends on where they
work in the facility and whether there is a direct relationship
or not.
Mr. Thompson. Can you repeat that for me again?
Mr. Battle. Sure. Relatives may work at the same facility.
Mr. Thompson. Sure.
Mr. Battle. But they should not be in a direct, under the
direct supervision of that person that they are working, where
they are working.
Mr. Thompson. Direct supervision, nor should they
participate in the hiring of the individual?
Mr. Battle. Correct. Correct. That is correct.
Ms. Lewis-Payton. That is a violation of VA policy for an
individual to hire their relative.
Mr. Thompson. And your testimony before us is that you are
aware of the complaint and you are investigating it?
Mr. Battle. We are looking in--yes, sir.
Mr. Thompson. Well I----
Mr. Battle. There has been an administrative activity going
on in regards to the Nurse Exec. And that is an ongoing
situation from a personnel perspective.
Mr. Thompson. Well Mr. Chairman, I am not certain but I
think since you are an Oversight Committee it might be proper
for you to ask for whatever findings those are. And I would
recommend that you, that this committee would look at any of
those nepotism allegations.
Mr. Coffman. Very well, Mr. Thompson. We will do that. And
thank you very much for your recommendation. We will follow
through on that.
Mr. Thompson. Thank you. I yield back.
Mr. Coffman. Mr. Palazzo, State of Mississippi.
Mr. Palazzo. Thank you again, Mr. Chairman. Quick question
for Ms. Lewis-Payton. When were you informed of the alleged
wrongdoings of Dorothy White-Taylor? And what actions have you
taken since then to end these prohibitive narcotic prescription
practices at the VA in Jackson?
Ms. Lewis-Payton. I think it is important to note that we,
the leadership at the medical center and at the VISN, requested
an OIG review of concerns that have been brought to our
attention. As you are aware, the criminal investigation has
been completed. And as was mentioned, an administrative
investigation is underway and we are not at liberty to discuss
it in this public hearing nor any actions that are in process
or may result from it.
Mr. Palazzo. So you kind of knew something was going on and
so you asked for the OIG investigation, correct? Or the
investigation? And that is when you actually learned of these
behaviors. And now she has been on suspension, indefinite
suspension since 2013? February, 2013?
Ms. Lewis-Payton. Sir, I will be happy to discuss personnel
issues related to individuals in a private setting. It would
not be appropriate to do so in this public hearing.
Mr. Palazzo. All right. I appreciate it. And again, I do
not want to, I mean, we have to recognize that there has been
some serious mistakes made in the past before we can begin the
process of moving forward so that these, this culture, this
institutional culture is changed, turned upside down on its
head so we can do what our number one mission is. And that is
to serve our veterans. Every one of you said you have a passion
for serving veterans. I know I mentioned my wife. She loved it.
She, I mean, she shot out of the house. You know, she would
stay late. I mean, I think she would pick up any veteran that
came in, she would just work them in. And she loved it. And it
was something that I know many, many VA employees do. The
doctors behind you have that passion. So this, I mean, there
are so many other agencies, so many other jobs you could
pursue. But people are drawn, because they are naturally
caretakers. And we have to have a way to weed out these bad
apples. Because they do not need to be anywhere near our
military veterans. I mean, the military has a way of weaning
out bad apples as well. And I hope, and I know this is, we are
talking about the VA center in Jackson. And I hope we emulate,
Congressman Walz mentioned, you know, stellar model VA medical
centers. There is no, with the number of veterans in
Mississippi we should be that number one, that number two
ranked in the best hospital system for the VA in America. I
mean, I want a competition. I mean, that should be you all's
charge everyday. We are going to be number one. And it is not,
you know, a decade from now. It is within arm's reach.
So I mean, I could go on about the oversight. I could go on
about the accountability. I look forward to personally meeting
with you all outside the committee setting to see what your
benchmarks are, where you are going, and then to help kind of
monitor it. Because as I mentioned, 2,500, I have been in
office two and a half years, 2,500 case files have been opened
in my office dealing with veterans and veterans' benefits. Not
all with the medical center. But, and they say, you know, I
want to be patient, I want to be kind about this, but I cannot.
Because patients in some regards when we are talking about
veterans that are 70 or 80 years old, they do not have time.
They need the care that, and they need it immediately. Because
they have earned it and they deserve it. And I just know that
you all are going to work hard. And know that if there is
anything that we can do, let us know. And I appreciate again
the chairman for allowing, you know, some non-VA Committee
members. Many of these issues are probably, you know, they are
aware of the VA inside and out. This is new to us. But I look
forward to learning a lot more about it. So thank you.
Ms. Lewis-Payton. Yes, sir. And I thoroughly enjoyed
working with your office in addressing the concerns. I have
become personally involved in that. And just so you know, the
motto in VISN 16 is the pursuit of perfection in veteran driven
care. We may not achieve perfection, but we will catch
excellence. So we are going to continue to work this. Because
we too think that this medical center should be the beacon of
what VA medical centers are across this country.
Mr. Palazzo. I yield back.
Mr. Coffman. Thank you, Mr. Palazzo. Mr. Harper, State of
Mississippi.
Mr. Harper. Thank you, Mr. Chairman. And again, thanks to
each of you for being here and to give us an opportunity to
discuss these issues. And it is, you know, perception is
reality. But a lot of the reality has created the perception.
And so we have to make sure that we equip you to turn things
around. Because the way it has been in the past number of years
is not acceptable, we would all agree with that. We have got to
do better. And you mentioned, Mr. Battle, 14 falls in
September. Just curious, was every one of those examined by the
orthopaedic surgeon on staff after the fall?
Mr. Battle. I do not know that I can give you that answer
off the top of my head, Congressman Harper. But I would be
happy to provide that information.
Mr. Harper. I am just curious, when a patient falls, it is
reported.
Mr. Battle. Right.
Mr. Harper. That is how you keep up with it. And is the
family notified if a veteran has a fall? Is the family
notified?
Mr. Battle. Yes, sir. Typically a couple of things will
happen. If someone falls there is an assessment done right away
of any injury or anything of that nature. If there is any
speculation of head trauma, for example, they go get a CT scan
right away. And the family is, or next of kin, is typically
called and told of the incident.
Mr. Harper. I am still concerned about the radiological
studies. And you mentioned, did you say potentially 58, Dr.
Parker?
Dr. Parker. Yes, sir. On rereview when it came up through
the radiologist----
Mr. Harper. Yes, sir.
Dr. Parker. --at Jackson they gave us 52 names, and then
they gave additional names. It ended up being 58, yes.
Mr. Harper. And of that 58 how many of those patients, or
the patients' families, are aware of this?
Dr. Parker. Well the allegation was that all 58 of the
studies were misread. And under independent review we were not
able to confirm that. But two families have been notified where
there were misreads that resulted in harm to the patients. And
there is an ongoing review.
Mr. Harper. So two out of 58----
Dr. Parker. Correct.
Mr. Harper. --means 56 have not been notified?
Dr. Parker. Yes, sir.
Mr. Harper. Is that what you are saying?
Dr. Parker. Yes, sir. Specifically there was no reason to
notify them because the allegations were not proven to be true.
Mr. Harper. I see. So you are saying that all 56 of those
are, there are no problems?
Dr. Parker. We asked an outside agency to completely review
those and that has been turned over to the Office of the
Medical Inspector so that again, back to perceptions and
realities, we have asked them to make that determination if
there is anything else?
Mr. Harper. Have they completed that yet?
Dr. Parker. It was given to them last week and they are
under review now.
Mr. Harper. How long will it take to review it? Ballpark,
best guess? I will not hold you to it, just best guess?
Dr. Parker. I would imagine within a couple of weeks we
will have a specific answer.
Mr. Harper. And Dr. Parker, Dr. Hollenbeck stated that the
threat of withholding performance pay was made to encourage or
extort physicians to sign collaborative agreements. What effort
has been made to terminate this practice?
Dr. Parker. Dr. Hollenbeck mischaracterized the pay. So let
me just briefly, there is, physicians are paid, there are three
elements to their pay. There is basic pay, there is market pay,
and there is performance pay. And that is to be able to compete
in the private sector for orthopaedic surgeons or primary care
physicians.
The performance pay is specific to a maximum of $15,000 per
year or 7.5 percent of whatever their annual salary is. So the
primary care physicians would be eligible for a certain amount.
That performance pay is specific, has to be a signed contract
that you will do something above and beyond, an achievable
measurable outcome. And there was discussion about those
physicians in primary care who went above and beyond and agreed
to collaborate with nurse practitioners. I am not sure that it
has been enacted. It was a discussion.
Mr. Harper. All right. I would certainly like any
additional information on that that you can share with this
committee, if I guess that is not my request to make but I
would appreciate the chairman taking a look at that. I would
like to see if that was available.
And then Mr. Battle, my time is almost up, a quick
question. Does Jackson continue to use temporary physicians or
any that did not maintain a direct supervisory role over nurses
to sign collaborative agreements?
Mr. Battle. I think, well thank you for the question,
Congressman Harper. I think to try to answer your question is
right now in primary care we do not have any locum tenens
working in primary care so we do not have them signing
collaborative agreements.
Mr. Harper. Thank you. My time has expired.
Mr. Coffman. Thank you, Mr. Harper. Panel you are now
excused. Today we have had a chance to hear from many different
accounts of the problems occurring at Jackson VA. I am not
convinced that VA has taken the appropriate steps to correct
these problems and I believe it is apparent that the veterans
served at Jackson have borne the brunt of these inadequacies.
This hearing was necessary to accomplish a number of items: to
identify the effects of overbooking, understaffing, lack of
supervision, and prohibited narcotics prescription practices on
the veterans served by Jackson VA Medical Center; to require VA
officials to explain their inadequate response to these obvious
deficiencies to determine what steps are being taken to correct
these problems; and getting answers for the preventable deaths
that occurred at Jackson as a result. Within 30 days I expect
VA to provide this subcommittee with a detailed written account
on what has been done to fix the many problems addressed today
that continue to occur at Jackson VA.
I ask unanimous consent that all members have five
legislative days to revise and extend their remarks and include
extraneous material. Without objection, so ordered.
I would like to once again thank all of our witnesses and
audience members for joining in today's conversation. With
that, this hearing is adjourned.
[Whereupon, at 12:38 p.m., the subcommittee was adjourned.]
APPENDIX
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