[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 
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                            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∥=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.]













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