By Sandra Basu
WASHINGTON — The role of nurse practitioners has become an issue in allegations of serious patient-care problems identified at the G.V. (Sonny) Montgomery VA Medical Center in Jackson, MS.
VA officials sought to reassure lawmakers at a recent hearing that it is enacting reforms to resolve those issues. “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,” VISN 16 Network Director Rica Lewis-Payton told lawmakers at a recent hearing.
The various problems at the Jackson VAMC have been well-publicized. Last March, the Office of Special Counsel sent a letter to the White House including various allegations, including poor sterilization procedures, chronic understaffing of physicians in primary care clinics, missed radiology diagnoses and improper nurse practitioner prescribing practices of narcotics.
A September 2013 follow-up OSC letter to the president pointed out that while VA reports substantiated some of the allegations, VA “routinely suggests that the problems do not affect patient care.”
“Given the apparent lack of progress in implementing the corrective actions, and the Whistleblowers’ ongoing concerns about patient safety, I find the VA’s response unreasonable. I am requesting through this letter an update on proposed reforms within 60 days,” the OSC letter stated.
Whistleblower Phyllis Hollenbeck, MD, a former Jackson VAMC family medicine physician testified that, as the Office of Special Counsel substantiated, the facility has lacked enough primary care physicians and that unsupervised NPs have outnumbered physicians 3:1 and sometimes 4:1 in the primary care area.
“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 have not had appropriate supervision and collaboration with physicians,’” she said.
Moreover, she added, “this same cavalier attitude and laxity by the medical center and VISN leaderships empowered the NPs to prescribe narcotics without physician supervision and without individual DEA registration numbers.”
In her current work in the Compensation and Pension Service, Hollenbeck said she often sees problems with diagnoses made by unsupervised NPs.
“Common stellar examples are heart disease, diabetes and asthma. Symptoms aren’t addressed or recognized and proper tests/treatments are delayed,” she said.
Hollenbeck criticized a VA proposal under consideration to make all NPs in the VA operate as fully independent.
“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,” she said.
Also testifying was Charles Sherwood, MD, another whistleblower, who retired from VA in May of 2011. He complained that affected patients were not informed after the discovery that a radiologist at the facility had neglected to examine all images of every radiologic study for which interpretation was provided. Sherwood expressed concern that VA’s finding that the radiologist’s actions did not affect patient outcomes.
“There was no responsibility for the VA to report these adverse events to the patients or their surviving family,” he told lawmakers in written testimony.
Meanwhile, VA officials insisted they are taking all allegations “very seriously” and working to correct problems at the medical facility.
“At no time can we as leaders put veterans in harm’s way,” Lewis-Payton said.
Lewis-Payton said, under new leadership, a plan was developed to transform the nurse practitioner-driven primary care model into “one with an equal number of physicians and nurse practitioners” for its 20 medical center-based primary care teams.
She also disputed Sherwood’s allegations that, for those radiological cases where it was confirmed that there was an error, an institutional disclosure was done.
“There is some additional work because of the concerns that have been expressed to 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,” she said.
Rep. Steven Palazzo (R-MS) told VA officials that he thought the Jackson VAMC should be striving to be a top facility in the country.
“With the number of veterans in Mississippi, we should be that No. 1 and No. 2 ranking of the best hospital system for the VA in America,” he said.
Lewis-Payton agreed, adding, “We are going to continue to work on this because we, too, think that this medical center should be the beacon of what medical facilities should be across this country.”
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.