Nurse Practitioners’ Role at Issue in Complaints about Jackson VAMC

By Sandra Basu

VISN 16 Network Director Rica Lewis- Payton

Rica Lewis-Payton, VISN 16 Network Director

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.

Whistleblowers Testify

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.

Addressing Problems

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.”

Comments (7)

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  1. Randy Beckett NP-C says:

    If NPs are prescribing without a DEA Number there is a clear violation of law. If a radiologist doesn’t report a finding this is negligence. It is unfortunate that Dr Hollenbeck has used the illegal action of a few of the hundreds of NPs working every day for our Veterans to push the political agenda of keeping NPs under physician control. Perhaps she also could of said it was a blessing this radiologist was identified so all radiologists could be audited.

  2. Deb Barton, MSN, NP-BC says:

    In the VA system, the hospital or medical center is assigned a DEA number. The individuals that have prescriptive authority within the system work under that number with a unique identifier. I got mine the day I signed on at the VA and went to the pharmacy and did my signature card. The unique identifier never changes although my signature card has changed due to marriage & divorce. I dare say Dr. Hollenbeck who works in the VA system knows this full well. Physicians, Physician assistants, Nurse Practitioners, PharmDs and anyone else that can write a prescription can all do so under the same regulation.
    You can have your own DEA and those individuals that hold dual positions in institutions that are not VAs will have one of those really expensive DEA numbers. Some individuals within the Federal system apply for a DEA number that can only be used in the Federal system and no where else, it is free. It can be used DOD and VA. The VA may go to that in the future for all employees but until they do, the NPs in Jackson were functioning legally.

  3. Dixie Carpenter MSN, NP-BC says:

    I take offense to the articles title as pinpointing NPs as their VAMCs source of the problem. To me it sounds like a systemic problem. If you are going to start criticizing NPs you better back it up with evidence and not slanderous comments singling out one group of people.

  4. Anne Liley, FNP says:

    Article above states
    “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.

    It is important to differentiate between “supervision” and collaboration. In Alaska at the state level, supervision is NOT required. There are numerous well done research articles that document independent NP’s, collaborating with their physician colleagues, provide safe, quality patient care with high levels of patient satisfaction. Collaboration with physicians and other members of the health care team such as pharmacists and social workers is essential in providing good quality care. If the staffing mix does not allow for adequate collaboration, then addressing this will make all the diffence.

    • Bonnie A. Lupo, MS, FNP-BC says:

      I support Miss Liley’s assessment to be clear of the difference between Supervision vs. Collaboration as most lay people do not understand the varying levels between MD’s and Mid-levels Providers and regulations of supervising vs. collaboration. One population providing direct patient care should not be identified as the “fly in the ointment” that can generalize poor care or outcomes. We are all well aware of some marginal if not incompetent MDs/NP’s/PAs within the VA and private sector that provide care today. Looking at the overall System for patient care, access and flow should and must include all members of the interdisciplinary team (IDT)in establishing their roles.

      I do feel some MD’s/MD Boards are threatened by the thought of supporting NP’s to function independently decreasing their value or worth. NP’s and PA’s can fill a need for medical care within their scope of practice and provide quality patient care.

  5. chuck vickrey says:

    Correct, Indiv DEA # are NOT required but may be soon infuture.I use the facilty DEA # and the MD knows thats a viable legal option. Also I practice under New Mexico with NO supervision by a MD, its a state where thankfully we are fully independent. The real root of the problem is the MD in question sees NP as econ threat.
    Lets push forward to parctice to our full capability.

  6. Karen Scott APRN CNP says:

    I have worked as an APRN CNP in the VA system for 14 years. I have always had my own DEA and have advised all APRNs to obtain their own. The federal system allows a waiver of cost if you are working in the federal system only. If not then you must pay to have the DEA.I know several staff, including physicians, NPs and PAs have used the facility DEA. Individual DEAs are coming and should be obtained now.

    NPs in our state of OKLAHOMA have supervision with our prescribing practice only. Although in our system it is easy to consult with a physician for guidance when needed. Just as they consult with APRNs skill sets. To make a statement that we should not be independent practitioners is just minimizing what we are able to do. I believe that every APRN is willing to seek out needed direction, unless the working environment is such they are mocked for asking. We all have a scope of practice in which we work. I have yet to meet someone who knows “everything”. We can all call into question diagnosis that were made with little data to support said diagnosis. Independent practice is a threat to some who feel as if their practice would be compromised.

    In the 1970s, it was the Drs. of Osteopathy who had to force the issue for practice. It is time to look at what our nation, what our veteran’s need. We are at a crossroads in which there are not enough practitioners to meet the needs of the many. With colloboration and good working relationships between medicine and APRNs problems should not be insurmontable.

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