A Message from ASA President Jane Fitch regarding the VA APRN Independent Practice Initiative - American Society of Anesthesiologists (ASA)

FDA & Washington Alerts

A Message from ASA President Jane Fitch Regarding the VA APRN Independent Practice Initiative

Below is a message from ASA President Jane C.K. Fitch regarding the the Department of Veterans Affairs (VA) Advanced Practice Registered Nurses (APRN) Independent Practice Initiative:

Dear Colleagues,

I am writing today to provide you updated information related to ASA’s work to halt the application of the Veterans Health Administration (VHA) Nursing Handbook to anesthesia services.   You will need to be logged-in to the members-only section of the ASA website to access all the linked documents.

This information should serve as a further update to my December 17 membership-wide telephone town hall conference call during which the VA issue was covered.  You may have also seen the Wall Street Journal article on this subject and my response to the reporter’s inquiries. 

As you know, policies and procedures related to anesthesia within the VHA are set by the current Anesthesia Service Handbook.  The current handbook, which has been in effect for over a decade, spells out three key requirements for the delivery of anesthesia in VA facilities.  They include: 1) in facilities with both physician anesthesiologists and nurse anesthetists, "care needs to be provided in a team fashion;" 2) the Chief of Anesthesiology is responsible for anesthesiology department policy in his/her VA facility; and 3) state licensure establishes the "breadth of practice allowable for a provider."

In contrast, documents obtained by ASA outside of formal channels (ASA's Freedom of Information Act (FOIA) request to VA was denied) last year reflected a draft "VHA Nursing Handbook" that sought to: 1) replace care "provided in a team fashion" with a requirement that all Advanced Practice Registered Nurses (APRN), including nurse anesthetists, "attain independent status;” 2) strip local Chiefs of Anesthesiology from decision-making, shifting privileging decisions to VA’s Washington, DC office; and 3) eliminate scope of practice as defined by the state – a federal preemption of state law. (VHA ONS Facts and Background Document)

The implications of this proposed Nursing Handbook are clear:  Veterans would no longer have the benefit of physician-led, team-based anesthesia care within the VA health system.  

ASA responded to this proposal with a three-pronged strategy targeting Congress, Veteran Service Organizations (VSOs) and The Department of Veterans Affairs.

Three Pronged Strategy

U.S. Congress Engagement

Upon learning about the proposed VHA Nursing Handbook, ASA immediately engaged in outreach to dozens of lawmakers to educate them on the proposed changes to current policies and procedures at VA.  ASA's lobbying team and our Key Contact/Grassroots Network reached out to educate and inform lawmakers and their staff about the implications of the VHA Nursing Handbook on Veterans health. I personally traveled to Washington, D.C. to participate in a variety of meetings with lawmakers and staff.  These efforts resulted in numerous lawmakers contacting VA to express concern about the elimination of team-based care and the related risks to Veterans' health. 

Anesthesiologist and Congressman Andy Harris, M.D. (R-MD-1) raised questions about this issue during a hearing of the House VA Committee Health Subcommittee

Lawmakers who are Veterans or who serve on the key House and Senate Committees on Veterans Affairs have been particularly engaged in this issue.  Notable examples include Representatives Michael Grimm and Ann Kirkpatrick.  Congressman Michael Grimm is a distinguished Veteran of the U.S. Marine Corps with service in Operations Desert Shield and Desert Storm.  He currently represents New York's 11th Congressional District.  Ann Kirkpatrick is a respected member of the House Committee on Veterans Affairs and represents Arizona's 1st Congressional District.  Representatives Grimm and Kirkpatrick have joined together to author a Congressional sign-on letter to VA Secretary Eric Shinseki expressing concern about the proposed VHA Nursing Handbook and its application to the surgical/anesthesia setting.  The letter was finalized recently.  Please contact Michelle Mathy in the Advocacy Division at M.Mathy@asahq.org to find out if your Member of Congress was a signatory to this letter.

Veteran Service Organizations (VSO) Engagement

In addition to Congress, ASA has engaged in outreach to numerous Veteran Service Organizations.  These organizations are leaders in protecting the interests of Veterans and have meaningful influence with Members of Congress and VA.   I have personally met with representatives of the nation’s most prominent VSOs.   AMVETs, the Association of the U.S. Navy, and other VSOs have taken note of the risks to Veterans associated with the proposed policy changes and have contacted Secretary Shinseki to express concerns.  We are truly honored to have their interest and support.

The Department of Veterans Affairs

ASA has also spent significant time and effort to engage key individuals with The Department of Veterans Affairs.   In addition to numerous formal communications sent to VA, ASA participated in a number of telephone conference calls with VA staff involved in the delivery of anesthesia care in the system. 

Independent of the ASA's efforts, the VA's own Chiefs of Anesthesiology have courageously stepped forward to raise concerns about the proposed policy changes and the Chiefs' exclusion from any role in the development of a new policy that directly impact anesthesia care in their facilities.  The Chiefs letter invoked VA’s own "Stop the Line" patient safety program.

ASA has also engaged in outreach to other internal VA physician stakeholders.

We have also engaged external VA stakeholders on this issue.  The AMA has been an important partner in our efforts.  As members of the AMA's Scope of Practice Partnership (SOPP), ASA worked with our colleagues in medicine on a formal communication to the VA Secretary signed by virtually every major medical specialty organization and state medical society.  The letter endorses the concept of team-based care as in the best interest of patients.  The letter is a powerful statement highlighting the unity of the medical community.  Additionally, the ASA presented on this topic at the 2013 AMA Interim Meeting in November before the SOPP group.  We also helped brief the AMA leadership and staff in preparation for the AMA's recent meeting with VA officials about this issue.  

The American Academy of Family Physicians, the American Osteopathic Association and the American Association of Oral and Maxillofacial Surgeons have also weighed in individually and sent formal comments to the VA expressing concerns about this proposal. 

Additionally, as has been previously reported, members of our Advocacy team and I met with senior VA Officials in December.  We expressed grave concern about the VHA Nursing Handbook.  We highlighted the patient safety implications of moving away from physician-led, team-based care and emphasized that the poor health status of patients in the VA system necessitated team-based care for optimal outcomes.  We also pointed out that the VHA Nursing Handbook could disrupt care at academic institutions affiliated with VA facilities.  If implemented, the nurses’ new policy would effectively create two separate care arrangements in affiliated facilities – the independent practice nurse arrangement and the team-based arrangement required by most states and Medicare.  The VA officials agreed to take our comments into consideration as the review of the draft VHA Nursing Handbook continued.


Our opponents have been hard at work.  Indeed, they have shown no signs of easing their activities.  We have obtained a copy of a letter written by members of the U.S. House Nursing Caucus in support of the VHA Nursing Handbook.  Additionally, the Association of American Colleges of Nursing is currently targeting anesthesiology and the Grimm-Kirkpatrick letter as part of their advocacy efforts.  Indeed, a coalition of nursing organizations have organized in opposition to ASA's efforts.  These groups have engaged in an aggressive misinformation campaign directed at Congress and seeking to dissuade lawmakers from further scrutiny of the VHA Nursing Handbook and its application to the surgical/anesthesia setting.

Current Status

We will not be deterred by the nursing community's efforts.  ASA is continuing its three-pronged strategy to advance patient safety. 

On the Congressional side, last week I spent three days in Washington, D.C. with our Advocacy Team in which we participated in a variety of meetings with lawmakers and staff regarding the VA issue.  The meetings were very productive.  Additionally, our lobbying team and Key Contacts/Grassroots leaders are still at work educating other lawmakers and staff and securing support for our Veteran’s health.  

Also as part of my stay in Washington, I continued to meet with leading VSOs.  I shared with these VSOs my perspective as a former nurse anesthetist and current physician.  During our meetings, I emphasized the value of physician-led team-based care and its importance in ensuring quality care in VA facilities. 

With regard to VA, we know the VHA Nursing Handbook has not yet been finalized. Nor has VA announced a date by which the decision will be made.  A decision could occur at any time.  As such, we are continuing our outreach efforts to key VA officials.  We are seeking follow-up meetings with the VA officials with whom we previously met.  These meetings will cover outstanding issues raised during our December meeting, as well as issues raised as part of correspondence we received recently from VA. The letter we received was in response to one of my formal inquiries to VA last fall.  We are grateful for the response from VA and are dedicated to continuously working with the Agency through this process.  The letter reflects that no decision has yet been made.  For now, the status quo exists while VA continues its meetings with stakeholders.  Indeed, the letter from VA leaves open the fundamental question: How will VA's proposed independent practice for nurses and the current team-based care provided for in the Anesthesia Service Handbook be reconciled?  We intend to continue our work to ensure physician-led team-based care prevails.

Tweaking a line from one of our past presidents, Roger Litwiller, our theme for this endeavor is "It's all about our Veterans."  We are being diligent in keeping this a bi-partisan issue, focusing on the lives and safety of our Veteran patients during anesthesia.  And rest assured, just as in anesthesiology, we always have a plan B and plan C.  Our Advocacy staff has us equally prepared with alternative plans related to this endeavor.  After all, nothing is more important than our patients!

I hope you find this information helpful.  Be assured that this issue continues to be ASA's top priority and that I, your EC and your AC remain committed to a positive outcome. 

Thank you for all you are doing for our patients and the ASA and thank you for your support.

Respectfully yours,

Jane C.K. Fitch, MD

President, American Society of Anesthesiologists

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