A physician formerly with the VA hospital in Jackson, Miss. warned lawmakers on Wednesday that a department proposal to permit all nurse practitioners to function independently and without physician supervision is a recipe for disaster.
That practice played a role in poor and at times fatal care given to patients at the G.V. Montgomery VA Medical Center, Dr. Phyllis Hollenbeck said in testimony before a House Veterans Affairs Committee oversight panel.
"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. The changes would make all NPs throughout the VA healthcare system operate independently, unsupervised, and without regard to state licensure requirements or scope of practice, she said.
According to the VA, its policy on nursing services, including for nurse practitioners, is still being reviewed and vetted for input from internal VA program offices and outside professional groups and agencies.
A 2010 Institute of Medicine report called "The Future of Nursing: Leading Change, Advancing Health" recommended removing scope-of-practice barriers for the nurse practitioners so they can practice to the full extent of their education and training, according to the VA. The department contends that the change would increase access to care and ensure continuity of the highest quality of care for our Nation's Veterans.
Now different states have different rules regarding physician supervision of nurse practitioners, with most not requiring it for NPs trained as Certified Registered Nurse Anesthetist, VA says. Even under the proposed change, according to VA, this group would continue to practice under the direction of chief of anesthesia or chief of surgery, depending on the administrative structure of the anesthesia program at a VA facility.
Hollenbeck told lawmakers that in her experience it would be a mistake to not require the NPs to operate as part of a team, under the supervision of a physician.
At Jackson, operating independently led to missed diagnoses for heart disease, diabetes, and asthma, among other illnesses, said Hollenbeck. And when diagnoses are made, she said, the diseases are not monitored or treated appropriately, resulting in the patient’s condition worsening.
Hollenbeck, who now works for the VA's Compensation and Pension Service, said she also found that NPs will not update current patient conditions, but cut-and-paste an earlier history or physical.
In one instance, she said, a veteran had white blood cell changes indicating the onset of chronic lymphocytic leukemia for 10 years that was finally diagnosed when severe pain led to discovery and subsequent biopsy of a mass in his abdomen.
Hollenbeck was one of five current or former VA employees at Jackson who filed whistleblower complaints that led to a VA investigation of the facility and ultimately a White House Office of Special Counsel review into investigation.
The OSC report, sent to President Obama on Sept. 17, faulted the VA's response to its investigation in some areas, including in its claims to address admitted problems. The report called the VA's response to the complaints, given concerns for patient safety, unreasonable and called for an update on its reforms within 60 days.
Dr. Charles Sherwood, former chief of ophthalmology at the Jackson hospital, was another whistleblower to testify on Wednesday. Sherwood previously filed a complaint after a court case brought by three female radiologists revealed the VA was aware that one of its doctors was not appropriately reading all the x-rays he was given.
Though the VA's Inspector General confirmed some of the complaints brought by Hollenbeck, it also concluded that the chief radiologist's failure to actually read all the x-rays brought to him had any significant impact on patient care.
Rica Lewis-Payton, network director of Veterans Integrated Service Network 16, which includes the Jackson facility, told lawmakers that the VA notified the family in the event they found a patient's care was affected by the radiologist's work.
"We know that a number of issues have been raised about this center, and we take those concerns seriously," Lewis-Payton said. "We work aggressively to identify and correct any errors, and we are adopting a series of significant reforms to improve the center."
She also told lawmakers the VA is holding people accountable for any wrongdoing -- ejecting claims by Hollenbeck and Sherwood that the department has covered up for staff and senior managers who have violated VA policy and even federal law.
But because the hearing was public, Lewis-Payton said, "I am not at liberty to provide specifics about what has been done in individual cases."