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‘‘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 

( 

Available via the World Wide Web: http://www.fdsys.gov 

http://www.house.gov/reform 


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MARK E. AMODEI, Nevada 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

Jon Towers, Staff Director 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

MIKE COFFMAN, Colorado, Chairman 

DOUG LAMBORN, Colorado 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

DAN BENISHEK, Michigan 

JACKIE WALORSKI, Indiana 

ANN KIRKPATRICK, Arizona, Ranking 

Minority Member 

MARK TAKANO, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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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 


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‘‘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. 


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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 lifethreatening 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. 


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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, 


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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 


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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. 


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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 adeVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

VACREP180 with DISTILLER
7 

quate 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 


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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– 


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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. 


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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 adverVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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tised 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. 


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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 ‘‘ReVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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gional 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. 


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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 reVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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porting 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, OfVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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fice 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: 


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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. 


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[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 


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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 


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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. 


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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 apparVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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ently 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. 


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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 LewisPayton 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 


VACREP180 with DISTILLER
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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 


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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. 


VACREP180 with DISTILLER
27 

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 


VACREP180 with DISTILLER
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(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/Federalprobe-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 


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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-veteranshospital-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-atmississippi-veterans-hospital.html?—r=0 

Death and Dishonor: Crisis at the VA 

Dina Gusovsky; CNBC documentary; cnbc.com/id/10001293?— 

source=vty%7C investigationsinc%7C&par=vty 

20 Buffalo VA patients test positive for hepatitis 

Jerry Zremski; Buffalo News; printed May 9, 2013; 

buffalonews.com/apps/pbcs.dll/artic le?AID=/20130509/ 

CITYANDREGION/ 130509231 

Mr. COFFMAN. Thank you, General. 

Mr. Jenkins, you are now recognized for five minutes. 

STATEMENT OF CHARLES JENKINS 

Mr. JENKINS. Thank you, Chairman Coffman, Ranking Member 

Kirkpatrick, and committee Members. I appreciate the opportunity 

to be here. 

My name is Charles W. Jenkins. I am the elected president for 

the American Federation of Government Employees at the G.V. 

Sonny Montgomery VA Medical Center. 

I represent over 900 employees at the medical center which includes some nursing assistants, licensed practical nurses, respiratory therapists, phlebotomists, and other direct care and nondirect 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. 


VACREP180 with DISTILLER
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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 


VACREP180 with DISTILLER
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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 


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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 ReVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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sources 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.’’ 


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> 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. LewisPayton 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. 


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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 


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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 HeadNurse, 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 


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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. 


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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. 


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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 


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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 faceto-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 WhiteTaylor 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 


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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—— 


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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. 


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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. 


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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 


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was because in the cases of Dallas, Atlanta, Jackson, Pittsburgh, 

Buffalo, and so on, these problems keep coming up like a big WhacA–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. 


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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 


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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. 


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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– 


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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. 


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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 


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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. 


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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? 


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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? 


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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. 


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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. 


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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 


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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. 


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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. 


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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 expeVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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riences 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. 


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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 


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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. § 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 conVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00066 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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cerned 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 conVerDate Aug 31 2005 12:41 Oct 15, 2014 Jkt 000000 PO 00000 Frm 00067 Fmt 6633 Sfmt 6633 Y:\85-869.TXT PAT

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tinue 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? 


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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. 


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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. 


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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 


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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 


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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 


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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? 


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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 


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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 


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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 


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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. 


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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. 


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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 


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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 


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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? 


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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 


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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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