[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
AN ASSESSMENT OF LEADERSHIP FAILURES AT THE MANCHESTER, NH VA MEDICAL
CENTER
=======================================================================
FIELD HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
MONDAY, SEPTEMBER 18, 2017
FIELD HEARING HELD IN PEMBROKE, NEW HAMPSHIRE
__________
Serial No. 115-30
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
30-376 WASHINGTON : 2018
COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION
MIKE COFFMAN, Colorado, Chairman
DOUG LAMBORN, Colorado ANN M. KUSTER, New Hampshire,
DAVID P. ROE, Tennessee Ranking Member
DAN BENISHEK, Michigan BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana 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.
C O N T E N T S
----------
Monday, September 18, 2017
Page
An Assessment Of Leadership Failures At The Manchester, NH VA
Medical Center................................................. 1
OPENING STATEMENTS
Jack Bergman, Chairman........................................... 1
Ann M. Kuster, Ranking Member.................................... 3
Honorable Jeanne Shaheen, U.S. Senate, New Hampshire............. 4
Honorable Maggie Hassan, U.S. Senate, New Hampshire.............. 5
WITNESSES
Carolyn Clancy, M.D., Deputy Under Secretary for Health for
Organizational Excellence, U.S. Department of Veterans Affairs. 7
Prepared Statement........................................... 34
Accompanied by:
Michael Mayo-Smith, M.D., M.P.H., Director, VISN 1, U.S.
Department of Veterans Affairs
Mr. Alfred Montoya, Jr., Acting Director, Manchester, NH VA
Medical Center, U.S. Department of Veterans Affairs
William E. Kois, M.D., Pain Management Specialist, Manchester, NH
VA Medical Center, U.S. Department of Veterans Affairs......... 9
Prepared Statement........................................... 35
Mr. David J. Kenney, Chairman, New Hampshire State Veterans
Advisory Committee............................................. 11
Prepared Statement........................................... 36
STATEMENTS FOR THE RECORD
Erik J Funk MD FACC, Non-Invasive Cardiology, Manchester VA
Medical Center Manchester, NH.................................. 38
Stewart I Levenson MD FACR, Medical Service Chief (ret), VISN 1
Medicine Service Line Manager (ret)............................ 39
Ritamarie Moscola, MD, MPH, CMD, CPE, Certificate Added
Qualification Geriatric Medicine, Certificate Added
Qualification in Hospice, Medicine Service Line Manager
Geriatrics and Extended Care, Medical Director Community Living
Center, Medical Director Hospice and Palliative Care, Medical
Director Home Based Primary Care, Medical Director Hospice and
Palliative Care................................................ 41
Mark Sughrue, ACNP, Cardiology Nurse Practitioner................ 42
Gary Von George, Business Service Manager........................ 44
Edward Chibaro, MD, John McNemar, DNAP, CRNA, Stephen Dubois,
CRNA........................................................... 46
QUESTIONS & ANSWERS FOR THE RECORD
Letter to Honorable David Shulkin from Jack Bergman and QFR's.... 48
VA QFR........................................................... 49
AN ASSESSMENT OF LEADERSHIP FAILURES AT THE MANCHESTER, NH VA MEDICAL
CENTER
----------
Monday September 18, 2017
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:35 a.m., at
the New Hampshire National Guard Edward Cross Training Complex,
772 Riverwood Drive, Pembroke, NH, Hon. Jack Bergman presiding.
Present: Representatives Bergman and Kuster.
Also present: Senators Shaheen and Hassan.
OPENING STATEMENT OF JACK BERGMAN, CHAIRMAN
Mr. Bergman. This hearing will come to order.
Welcome to all who came out this morning to this beautiful
new Guard building that we have an opportunity to have this
hearing in. As you know, around the country our National Guard
steps up every day in many different forms to do what needs to
be done, and to be able to work out of facilities like this
makes the job, I think, quite a bit probably more productive.
Thank you to all of my colleagues here at the table and
those of you in the audience who take the time and effort to
make projects like this become reality.
Thank you to all of you who have joined us in the audience.
Today we will discuss issues with the five witnesses at the
table but will not be able to field questions from the
audience. If you would like to write questions, any questions
that you have down, we will be happy to take them back and we
will answer them through the office later.
Prior to getting started, I would like to ask unanimous
consent that Senators Hassan and Shaheen from the State of New
Hampshire be allowed to participate in today's hearing.
Without objection, so ordered.
And, by the way, thank you for joining us. I know that you
all have to go back into session here this afternoon, and you
potentially have flights to catch. So depending on how long the
hearing goes, if you see somebody leave, it is because they
have to go back to Washington, D.C.
We are here today to address failures of facility and VISN
leadership to identify and resolve problems at the Manchester,
New Hampshire VA Medical Center. Many of these problems involve
the same issues that arise in VA medical centers around the
country. At least 12 whistleblowers have come forward to report
a series of problems occurring at the Manchester VA Medical
Center. Some have provided statements for the record, and I
would like to also ask unanimous consent that these statements
be entered into the hearing record.
Without objection, so ordered.
Mr. Bergman. These whistleblowers tried to go through
proper channels and find solutions to these problems. But as we
have seen happen over and over again in VHA, complaints were
either ignored or went unaddressed. In Manchester, an operating
room was abandoned due to a fly infestation, surgeries were
canceled after discovering what appeared to be rust or blood on
instruments that were supposed to be sterile, and thousands of
patients struggled to get care because the system for getting
non-VA care was severely broken.
Notably, in 2016, VA gave the Manchester Medical Center a
four-star rating out of a possible five. It has been ranked
above average for overall patient experience and near the top
for minimizing the amount of time patients had to wait to see
providers.
However, a Korean War veteran is reportedly suffering the
effects of a large tumor on his spinal cord that was apparently
missed by VA physicians for more than 20 years. Another veteran
waited more than four weeks to be seen by an oncologist
following a diagnosis of lung cancer.
I have to question a rating system that gives out such a
high score while these and many other issues we will discuss
today were occurring during the same period of time.
To be clear, I wholeheartedly believe that the frontline
and clinical employees at the Manchester VA Medical Center
demonstrate hard work and dedication every day and deliver
excellent service to veterans. However, it is also clear that
serious, immediate leadership changes are needed at this
facility to right the ship and to ensure that these employees
are in a position to provide the best possible care that they
can.
After reading VA's written testimony, I am encouraged by
the actions they are taking to attempt to remediate the
problems at the Manchester VA Medical Center. However, I look
forward to hearing from all the witnesses on our panel to
discuss what more must be done to ensure that progress
translates into actual results.
I now yield to Ranking Member Kuster for her opening
remarks. And, by the way, thank you, Ranking Member Kuster, for
spearheading this and getting us all up here, because of all
the Committees that we have in the 115th Congress, the
Veterans' Affairs Committee is far and away the one where we
work--there are no party lines here. This is all about the
veterans, and I am proud and honored to have Representative
Kuster up here as my partner. So, I yield to you.
OPENING STATEMENT OF ANN KUSTER, RANKING MEMBER
Ms. Kuster. Thank you, and thank you, Chairman Bergman, for
coming to New Hampshire and making the trip. A month ago I had
a great trip out to Chairman Bergman's district, and we had a
good hearing in Traverse City, Michigan, and I am delighted to
have you here on behalf of our Oversight Committee at the House
Veterans' Affairs Committee. Welcome to our beautiful state.
I am also pleased that both Senator Shaheen and Senator
Hassan can be with us today. I want to thank them for taking
the time out of their busy schedules.
And I want to thank our witnesses, especially Dr. Kois, a
whistleblower that has come forward, and Dr. Levenson and other
whistleblowers that are with us in the audience today.
I want to welcome Commander Kenney and thank you for
stepping up into a leadership role as co-chair of the task
force. Commander Kenney is the chair of our State Veterans
Advisory Committee, and he has been nominated by Secretary
Shulkin to co-chair the task force that will review health care
services provided to our New Hampshire veterans. I appreciate
your extra effort.
Like many, I was appalled to hear about the breakdown in
care, in coordination, in quality of care, and particularly in
patient safety and very serious infrastructure issues that
arose at the Manchester VA Hospital. It took brave
whistleblowers, several investigations, the work of several
congressional offices and agencies, as well as the media to
uncover the serious problems at the Manchester VA Hospital.
In 2015, we started to see symptoms of the problem after
Michael Farley, a New Hampshire veteran, was left permanently
disabled because Manchester's Urgent Care Center failed to
transfer him to a hospital just two miles away. At that time I
asked the Inspector General to investigate Manchester's
procedures for treating stroke patients. The IG's report found
Manchester failed to follow its own procedures because of the
facility's culture. Employees thought they could administer
care when the hospital did not have the specialists and
capability to provide acute care for stroke patients.
It is clear now to everyone that the Manchester VA Hospital
needs a top-to-bottom or bottom-to-top transformation, and that
is why we are here today, to look at what must be done to
ensure that our New Hampshire veterans are receiving the
highest quality of care at Manchester VAMC from the community
providers and from the hospital itself.
VA can start by holding all of its employees accountable,
from the hospital and network leadership to the administrative
and frontline staff. Secretary Shulkin made the right decision
to remove the hospital director, the chief of staff, and the
head of nursing services, and I know that efforts are underway
at recruitment for these important positions as we speak.
VA leadership who knew about the reports of substandard
care and failed to act should be held accountable. Supervisors
who retaliate against whistleblowers should not be employed at
the Manchester VA Hospital. The culture at the Manchester VA
Medical Center must change so that our providers follow
procedures and clinical guidelines, and so that providers and
veterans are supported and unafraid to report problems when
they arise.
New Hampshire is the only state in the continental U.S.
without a full-service VA medical facility. Manchester should
be a model for delivering quality care both in the hospital and
in the community. It should be the model for solving
administrative challenges so our veterans can easily access
care. But instead, Manchester is a glaring example of the same
challenges that VA hospitals and networks face throughout the
country to meet patient demand and coordinate care under the
current Choice program. Our facility here in Manchester needs
serious repairs. Patients wait too long to receive care at the
hospital and through the Choice program. Providers at both the
hospital and in the community have difficulty coordinating care
because of the administrative burden. This must change.
I want to know how the $30 million will be spent and if it
will truly address the infrastructure and care coordination
problems in Manchester, or if more funding will be needed to
ensure that the VA has the resources in New Hampshire to meet
the needs of our veterans. The task force is charged with
making recommendations for the health care needs of our
veterans, and I hope they will thoughtfully examine how we can
improve care coordination, including the model that is very
successful now in the North Country here in New Hampshire, and
how we can coordinate care with our community providers.
We rely on our community providers to provide acute care
and inpatient care, and that is something that should continue.
We need to determine what is the best course forward. I am
eager to see what the task force recommends, and as we move
forward to improve care for New Hampshire veterans, the
patients, the veteran service organizations, VA providers and
community providers should all have a stake in the decisions
that are made.
I hope we can use what we learn here today as a starting
point to work together to develop commonsense solutions to VA's
challenges and to ensure that what has happened in Manchester
will not be repeated. Veterans must be able to trust that the
VA will provide them with the best quality of care.
This will take some time, but I believe we can work
together to bring New Hampshire veterans the highest quality of
care that they deserve, and I yield back my time.
Mr. Bergman. Thank you, Ranking Member Kuster.
Our Committee custom is generally to ask other Members to
waive opening remarks. But seeing it is just the four of us up
here today, I would like to allow Senators Shaheen and Hassan
the opportunity to provide some brief opening remarks as well.
Senator Shaheen?
OPENING STATEMENT OF SENATOR JEANNE SHAHEEN
Senator Shaheen. Thank you very much, Chairman Bergman and
Ranking Member Kuster, for convening this field hearing and for
shining a spotlight on the efforts to correct problems at the
Manchester VA Medical Center. I very much appreciate your
willingness to give me and Senator Hassan the opportunity to
join you and to say a few words.
I believe very strongly that the Federal Government has a
contract with those who have served in uniform. We have a duty
to provide our veterans with the quality health care that they
have earned and that they deserve.
We in Congress also, as well as leaders at the VA, have a
responsibility to identify any problems where they exist, to
hold people accountable, and to make things right. In the case
of the Manchester VA Medical Center, I am grateful to the
whistleblowers, represented today by Dr. Ed Kois, for coming
forward and for your persistence in raising serious concerns
about the treatment of patients at the Manchester VA. I also
respect that you and the other whistleblowers continue to be
determined not only to raise questions but to be part of the
solution. So, thank you for that.
I know all of us appreciate Secretary David Shulkin's
hands-on approach to the challenges here in Manchester,
including his decisive action to remove top management at the
center and to order a range of reviews, improvements, and new
hires. During his visit last month, I was heartened by his
decision to name a task force to come up with a plan by January
for offering full services to New Hampshire veterans, and he
put on that list the prospect of a full-service veteran's
hospital. As Congresswoman Kuster has said, New Hampshire is
the only state in the lower 48 that does not have a full-
service VA hospital. We have been waiting for this for a very
long time.
In the meantime, I hope that task force will take steps to
ensure that care in the community programs, in particular the
Veterans Choice program, is working effectively for New
Hampshire veterans. And as Congress considers reauthorization
of the Choice program, we need to look very closely at how we
can make that program work better.
I am grateful to Acting Medical Director Al Montoya and
Acting Chief of Staff Dr. Brett Rusch for stepping into a very
difficult situation and jump-starting necessary changes and
reforms.
And in addition, I want to salute the health care providers
and support personnel, the frontline folks at the Manchester
VA, who despite the recent difficulties have stayed focused on
providing high-quality care to the people they serve.
As we go forward, I know that we all share the same goals,
to correct deficiencies that have been identified at the
center, to restore trust in the center's leadership, as well as
accountability at all levels, and to ensure that our New
Hampshire veterans receive the excellent health care they
deserve.
Thank you very much, Mr. Chairman, and I look forward to
hearing from our witnesses and appreciate their being here
today.
Mr. Bergman. Thank you, Senator Shaheen.
Senator Hassan?
OPENING STATEMENT OF SENATOR MAGGIE HASSAN
Senator Hassan. Well, thank you very much, Chairman Bergman
and Congresswoman Kuster, Ranking Member, for convening this
hearing. Senator Shaheen, it is always good to be in the same
hearing with you. And to all of our witnesses, thank you so
much for being part of today's hearing. Dr. Kois, I thank you
and all the whistleblowers as well for your persistence and
diligence in standing up for the men and women, the veterans
treated at our Manchester VA.
Veterans across New Hampshire and the United States of
America have demonstrated a selfless commitment to keeping our
Nation safe, secure, and free, and we have to ensure that every
single one of our veterans receives the care that they need
and, to Senator Shaheen's point, and to all of the legislators'
points here that they have earned.
All of us here today are outraged by the poor conditions
and quality of care that were alleged by whistleblowers, and I
thank Dr. Kois and his fellow whistleblowers for help bringing
this to our attention.
I appreciated very much that last month Dr. Shulkin visited
the Manchester facility to learn about these concerns, but his
visit has to be just the first step of many to address the
problems raised by whistleblowers. We have to continue to work
together to get to the bottom of these issues and to make sure
that our veterans get the high-quality care that they deserve,
and field hearings such as this one will help us do that.
I believe that we need a thorough, independent review
process which includes interviews with clinicians and patients
in order to address these concerns and prevent future failures
in care for our veterans.
I also continue to support a full-service VA hospital in
New Hampshire, and I believe that we need to improve
coordination and communication at the VA and more broadly,
because the unfortunate reality is that health care is far too
siloed. I am going to continue to work with everyone here and
partners at the state and Federal level to ensure that we are
fully honoring the commitments we have made to our veterans.
I also join all of my colleagues here in thanking the hard-
working health care providers at the Manchester VA. We have
heard time and time again, since the whistleblower report came
forward, from individual veterans who are very, very grateful
to the health care providers who work with them at the VA, and
I want us to support those providers and move forward again so
that every veteran in New Hampshire knows that they are getting
the highest possible quality care in a setting and in a timely
way that makes sense for them.
Thank you.
Mr. Bergman. Thank you, Senator Hassan.
With that, I now welcome the panel that is seated at the
witness table. On the panel we have Dr. Carolyn Clancy, Deputy
Under Secretary for Health for Organizational Excellence at the
Department of Veterans Affairs. She is accompanied by Dr.
Michael Mayo-Smith, Network Director for VISN 1, and Mr. Al
Montoya, Jr., Acting Director of the Manchester VA Medical
Center. Also on the panel we have Mr. David Kenney, Chairman of
the New Hampshire State Veterans Advisory Committee. And
finally we will hear from Dr. Ed Kois, a Pain Management
Specialist at the Manchester VA Medical Center, who has brought
many of the issues we will discuss here today to light.
Dr. Clancy, you are now recognized for 5 minutes.
STATEMENT OF CAROLYN CLANCY, M.D.
Dr. Clancy. Good morning, Chairman Bergman, Ranking Member
Kuster, Senators Shaheen and Hassan. Thank you for the
opportunity to participate in this hearing to discuss VA's
response to the concerns raised at the Manchester VA Medical
Center. As you mentioned, I am accompanied by Dr. Michael Mayo-
Smith and Mr. Montoya.
I want to specifically mention our appreciation for Mr.
Montoya's stepping into a tough situation and handling it
admirably.
First let me say that VA appreciates the actions taken by
whistleblowers when it comes to safeguarding care for our
veterans. I thanked Dr. Kois when we met for the first time
this morning. We are committed to always protecting those
whistleblowers from retaliation. VA has and will continue to
take immediate action when responding to whistleblower concerns
at any VA facility across the country. The Office of the
Medical Inspector and the Office of Accountability and
Whistleblower Protection were sent to conduct a top-to-bottom
review of the Manchester VA, and the Secretary rapidly
recognized the need for a new leadership team. We look forward
to this opportunity to build trust between VA and our veterans
and to keep Congress up to date on our progress.
Our focus in Manchester now is on the way forward and
ensuring that high-quality, timely access to care is the
default in all aspects of medical center operations. Currently,
the medical center is executing a plan that focuses on five key
areas: rebuilding leadership; restoring trust; improving care;
fixing the Veterans Choice program's local operations; and
designing the future.
To address the lack of consistent leadership at the VA, we
are recruiting nationally for the medical center Director,
Chief of Staff, Nurse Executive, Chief of Medicine, Chief of
Surgery, Chief of Primary Care, Director of Urgent Care, and a
physician leader for the newly-created Office of Community
Care.
Second, we are also working on restoring the trust of our
veteran staff and community stakeholders. Medical center
leadership has taken swift action to ensure that all members of
the medical center, including clinical staff, are included in
key decisions. As noted, VA immediately responded to the
whistleblower allegations with thorough reviews from several
offices, and we have an external non-VA review being done by an
organization called Lumetra of our myelopathy cases and the
cases that we have reviewed internally. These will be Board-
certified physicians in the appropriate specialties who are
bringing fresh eyes to the clinical evidence at hand.
Finally, there has been consistent structured public
reporting and listening sessions with veterans, staff, and
community stakeholders to discuss progress at the Manchester
VA.
To improve timely access to care, we have committed over $5
million to hiring additional staff. This includes several key
positions on the cardiology staff and two new patient-aligned
care teams for primary care. We have accelerated community and
academic partnerships to support the medical center and are
looking to open an accredited rehabilitation program for
chronic pain and purchase needed equipment for surgery.
We have also restarted nuclear medical testing at the VA,
Manchester, with the goal of adding stress tests by October. We
have successfully hired two suicide prevention coordinators, a
women's health medical director, and a women veterans program
manager, and working very hard to ensure all areas affected by
the flood are open and operational by December 2017.
On July 26 of 2017, we created a new Office of Community
Care in Manchester that consists of over 30 staff, including 17
new physicians dedicated to ensuring our veterans have
assistance in navigating all aspects of care in the community.
This office processed and cleared a backlog of approximately
3,300 pending consults. With a change in process, 95 percent of
all pending consults are being taken care of within two
business days.
Additionally, we have taken a proactive approach with our
community providers and assisted in ensuring that bills from
our providers within the Veterans Choice program network and
our community care providers are being processed in a timely
manner. We have established routine calls with our Veterans
Choice program network's field operations staff, embedded a
network representative, and fostered a relationship of
collaboration.
We are positioning the Manchester VA Office of Community
Care to be able to handle any changes to the Veterans Choice
program in the future as we continue to work with the Congress
to improve that program.
Finally, Secretary Shulkin will be creating a Subcommittee
of VA, a Special Medical Advisory Group--this is one of our big
Federal advisory committees--to make recommendations on the
future of the VA care delivery model for New Hampshire
veterans. The Subcommittee membership will consist of strong
representation from New Hampshire veterans, VA Medical Center
staff, including representation from the whistleblowers,
regional and national subject-matter experts, and leaders of
the New Hampshire hospital and provider communities.
Under the direction of the advisory group, the Subcommittee
will undertake a careful review of data and develop innovative
solutions for improvement. The Subcommittee will take the grave
infrastructure issues at the Manchester VA into account when
developing its recommendations. The advisory group will, in
turn, make recommendations to the Secretary through the Under
Secretary of Health by the end of January 2018.
We look forward to this opportunity for our new leadership
to restore the trust of our veterans and continue to improve
access to care inside and outside VA. Our objective is to give
our Nation's veterans the top-quality care they have earned and
deserve. We appreciate this Subcommittee's support and
encouragement in identifying and resolving challenges as we
find new ways to care for veterans.
My colleagues and I are prepared to respond to any
questions you have.
[The prepared statement of Dr. Clancy appears in the
Appendix]
Mr. Bergman. Thank you, Dr. Clancy.
Dr. Kois, you are now recognized for 5 minutes.
STATEMENT OF WILLIAM E. KOIS, M.D.
Dr. Kois. Thank you. I want to thank the Committee here.
Bringing light onto this subject is a wonderful thing. I would
also like to thank the whistleblowers. I may just be the pretty
face that is sitting at the desk, but they are the substance
behind me, and I want to make sure that everybody reads their
statements because they are worthwhile to look at and they have
different perspectives. It is just not my perspective.
I would like to thank the press. I think without the free
press, we probably wouldn't be sitting here.
And finally, I want to thank the veterans of our state.
They are what has driven this whole process, and we hope to
continue to work for them. None of the whistleblowers have quit
and are looking for settlements. We are looking to make the
situation better for our veterans, and we hope to work with
everybody, with Congress and with the Administration and with
veterans and veteran organizations, and with community leaders
and providers to really come together.
New Hampshire is a unique state. It is like a little
village. If you have lived here any length of time, you start
to know people. That is good and that is bad. You can't make
too many people angry at you. But on the other hand, you can
bring in resources in an amazing way, and that is what I hope
to have happen with what is going on here, is that we come
together and call our resources from a variety of different
institutions and make something better.
My name is Ed Kois, and I am a VA physician at the
Manchester Medical Center. I have worked there since 2012. I
have a variety of different hats. I have worked in the spinal
cord clinic, the pain clinic, the amputation clinic, the
traumatic brain injury clinic, and the physical medicine
clinic. During that period of time, I have grown to love the
veteran population.
Prior to that, in '86, I started working in New Hampshire
and had a traditional private practice until 2012, and I have
to say the veteran population is completely unique. When I hear
people say let's just privatize things, I don't think they
understand the uniqueness of our vets and the uniqueness of
their needs. And I think that we have to really think long and
hard about that.
I receive a paycheck from the VA, but I consider myself an
employee of the veterans of the state, and that is who I work
for, and that is why I started to talk to other physicians when
concerns about patient care started to raise its head.
After almost two years of utilizing all avenues available
to me and not receiving satisfactory solutions, I eventually
started to talk to Dr. Levenson, Dr. Funk, and some of the
other physicians that initially were on my floor, and then we
started to talk to other physicians throughout the building and
found that they had similar complaints.
At that point we had all sort of been isolated. No one
really talked to each other, but it was great because we were
able to say, hey, are you having this type of experience? And
we realized we all were. And so for that reason we eventually
formed the whistleblowers, but I can tell you we represent a
large number of physicians and nurses in our facility who had
similar problems.
The Boston Globe article on July 16th really broke this
story right open, but the groundwork had been laid by Senator
Shaheen and by Representative Kuster. We met with them earlier,
discussed our concerns, and they were able to direct us to the
Office of Special Counsel. The Office of Special Counsel was
wonderful in dealing with them.
I am going to level my first complaint. My first complaint
is that the Office of Medical Investigation that was initially
done at the request of the Office of Special Counsel was a
sham, and I feel it was not representative of good work. Later,
if you people want to ask me about it, I would be glad to talk
about that.
But that, I think, is troubling, because they are supposed
to be the front line to prevent catastrophe from happening, and
it didn't happen.
The problems, however, in the Manchester VA that had been
well exposed by the Boston Globe are not unique to our VA. I
believe if you read the Globe's article yesterday, they talked
about many other facilities. There was a recent facility in
Memphis, there have been throughout the country, and I think
unless we get a handle on really what is happening in the VA
system, this is going to continue.
In a nutshell, we have really dedicated people who work in
the system, but we have a bureaucracy that is so top-heavy and
so slow to react that it is problematic. I liken it to a 900-
foot ship or a barge that is going down a river. It can't make
the quick turns that are needed in today's changing medical
care, and we need nimbleness.
One of the things that really delighted me in meeting Dr.
Shulkin is he gets it. He gets the fact that we have to be
nimble and that we have to react and do the right thing, and we
can't let our cumbersome rules get in the way.
The publication in the Globe resulted in the meeting with
David Shulkin. On August 4th he met with eight whistleblowers,
and the other thing that impressed me was he listened to us. He
didn't tell us what we needed to do. He listened to us, and
then he took quick action. He removed the three individuals at
the top, but those aren't the only three. If you read some of
the other reports from the whistleblowers, there are other
people within our system that we need to continue to evaluate.
The other thing, and I hate to bring unpleasant stuff, but
our VISN didn't support us. Now, maybe it is because we are in
the North Woods or we are in the hinterlands, but we complained
to the VISN incessantly on this. Dr. Levenson complained, I
complained, and we did not see the support at the VISN level to
make these actions. In fact, we felt ignored, and that is
troublesome when you are sitting in front of a patient like I
was seeing some of them have disastrous results and not being
able to get the resources that were appropriate for them.
Now, Dr. Shulkin named Acting Director Montoya and Dr.
Rusch, and I have to say they are both nice guys, and I think
they are trying very hard, and I am glad to have them on the
team and glad to work with them. They have tried to already
start to institute things, but this is a process that is going
to take months and months, or years, to really complete and
turn around. We still have tremendous problems in the
operations of our ORs. We have a situation right now that I
have talked to Al about, and we have a whole group of
practitioners who are ready to walk out, and I don't think
people realize the seriousness of it, and that has to be
addressed.
I also have to comment that Al and Brett have tried to
include us. I am going to be part of the new search committee
for the chief of staff, and other physicians are going to be
involved with that.
Finally, I think that what has happened in the VA--we can
talk about this for the rest of this morning, but I think it is
emblematic of other issues throughout the VA system, and I
would hope that what we learn in Manchester and what we do in
Manchester can be used in a nationwide change of the VA system.
I hope that we are able to get a full-service hospital here. I
hope that we get a new facility, and I hope that we are able to
community partner.
Thank you.
[The prepared statement of Dr. Kois appears in the
Appendix]
Mr. Bergman. Thank you very much, Dr. Kois.
Mr. Kenney, you are now recognized for 5 minutes.
STATEMENT OF DAVID J. KENNEY
Mr. Kenney. Thank you, Mr. Chairman, Ranking Member Kuster,
Senator Shaheen, Senator Hassan, and distinguished Committee
Members. It is an honor to submit this testimony as the current
Chairman of the State Veterans Advisory Committee. Our
Committee is comprised of 19 veteran service organizations, as
well as advisors from a number of state agencies in New
Hampshire that provide services to veterans and their families.
I should also state for the record that I am a 40-year Navy
veteran and currently do not obtain care at the Manchester VA.
As part of the New Hampshire veteran leadership, I have
heard various individual complaints with the VA over time.
However, the revelations by the Boston Globe article were
appalling. The article alleged alarming levels of systemic
breakdown at the VA Manchester and an apparent lack of
commitment to fixing the issues.
Since the Boston Globe article was published, I personally
participated and/or observed a number of meetings related to
the VA and Manchester, including the public meeting held by the
whistleblowers to air their concerns. I am pleased that these
deficiencies have been uncovered and believe that the exposure
offers a great opportunity to not only fix the issues at VA
Manchester but to potentially develop some valuable best
practices which could be deployed to other VA facilities around
the country.
It is, however, unfortunate that we are here today once
again providing testimony that cites problems and deficiencies
with the VA medical system. In fact, the need for
whistleblowers or a protection system for them implies an
underlying lack of genuine accountability.
One could surmise that if the system worked as it should,
there would be no need for whistleblowers, reactive repairs,
and veterans would get the best care that they deserve. Today
there are thousands of veterans in VA facilities across the
country. Most are there because our Nation put them there. When
our Nation issued the call to war, these men and women answered
because they took the oath to do so, but they did not die on
the battlefield. They came home and in many cases later
suffered the manifestations of disease caused by chemicals we
employed in the jungles of Vietnam, from the oil fields and
burn pits in the Middle East, from the atomic waste at the
atolls and the Marshall Islands and, sadly, poisoned by the
water on their own U.S. bases.
In today's conflicts, body armor protects the core but not
the limbs. We now have more amputee survivors than we have ever
had before. And there are the hidden wounds of TBI and PTSD,
which cannot be repaired by a quick pill or by some one-stop
therapy.
This is the reality of the VA's responsibility. It is the
reality of our responsibility.
If you think about it, great medical care transcends the
VA. When we go to our doctor, do we not expect to be treated
properly? It is reasonable to expect that when a doctor orders
a test or some follow-on procedures that we expected those to
be done professionally and in a timely manner. So why would we
continue to stymie the kind of care for our Nation's heroes?
Why do we continue to mire them in a system of complex
bureaucracy, having to navigate and fight and make hundreds of
phone calls just to get basic services?
The answer is simple: If we are truly serious about
providing excellent care to our veterans, then we need to
change our culture of bureaucratic blockage and budgetary
excuses for not providing what is needed. The culture change
must also embrace the notion that doctors and medical staff
know what is needed, and it is the Administration's job to
figure out how to best get that done in a timely manner. Do
that, and we can truly say that we have made progress?
Thankfully, not all is bad news. Director Montoya has
advanced a number of significant improvements to solving many
of the problems and deficiencies discovered since he arrived in
July of 2017, and the VA Manchester has been lauded by many
veterans for the superb quality care that they receive there.
But challenges remain, including access to care, ensuring
the best technologies are available, improved access to primary
care physicians and, when needed, a properly functioning, fully
funded Choice program. It is imperative that the new leadership
will create an environment of trust for both the staff and the
patients alike. Accountability and a pursuit of excellence
should be a daily routine. When a patient's safety is at stake,
there can be no compromise.
I have been asked to serve as a co-chair on Secretary
Shulkin's task force Subcommittee to review and make
recommendations for improvements at Manchester VA. Part of our
charter is to ensure that we think creatively and entertain all
reasonable options that would be most prudent to implement and
send to the Secretary for his consideration. It is my sincere
hope that our recommendations will get the full support of the
VA Secretary and the Congress' financial backing.
Our process will be closely monitored by the veterans here
in the State of New Hampshire and around the country. We cannot
fail them any longer. Their lives depend on it.
In closing, General Washington wrote a letter in 1781 to
Governor Trumbull in Connecticut, and what he said was this:
``Permit me, sir, to add that the policy alone in our present
circumstances seemed to demand that every satisfaction which
can reasonably be requested should be given to those veteran
troops who, through almost every distress, have been so long
and so faithfully serving our states.''
General Washington strongly believed in the importance of
supporting veterans in all aspects. We need to keep that
visionary wisdom in the forefront of everything that we do for
veterans.
Thank you for your consideration of my testimony, and I
remain at your service to answer any questions.
[The prepared statement of Mr. Kenney appears in the
Appendix]
Mr. Bergman. Thank you, Mr. Kenney.
The written statements of those who have just provided oral
testimony will be entered into the hearing record.
We will now proceed to questioning.
Ranking Member Kuster, you are recognized for 5 minutes.
Ms. Kuster. Thank you, General Bergman.
And thank you to our witnesses for appearing with us today
and for your excellent testimony.
I am going to take my first round of questions to focus in
on that Mr. Kenney said that Manchester could provide valuable
best practices that could be shared across the country, and I
believe, Dr. Kois, you were taking a similar approach.
I just want to ask Mr. Montoya if we could focus in on this
issue of the Choice Act and community care. What are the steps
that you are taking to bring better practices? And then Mr.
Kenney had a very important point, a properly functioning and
fully funded Choice program, if you could walk us through that.
And then I have one other question for Dr. Kois.
Mr. Montoya. So, thank you so much for the question and for
the opportunity to be here today.
I think as a veteran myself who gets 100 percent of my
health care within the VA, this mission has been a very
personal one for me. It has been very long days, but I know
that at the end of those days the veterans are getting the care
that they deserve.
So the best practice as far as the Office of Community
Care, the first week that I was at the Manchester VA I
recognized the need to really transform the delivery model for
Choice for the veterans within the State of New Hampshire. So I
essentially enlisted the help of some subject-matter experts
who have helped us throughout the network and standing up
traditional offices of community care. These are models that
are based very much on the models that you are familiar with up
in the North Country where there are case-managed models with a
nurse case manager, as well as MSAs or medical support
assistants that help those case managers.
So we essentially took that model and scaled that to one
that would be successful here in Manchester. I will tell you
that immediately there were 3,200 pending consults, so we had a
lot of work that we had to do in order to be able to make sure
that veterans were getting the best access to care.
The processes that we have put into place now require there
to be six different nurse case management teams, which are all
supported by a nurse manager, as well as a physician leader who
reports directly to the chief of staff of the organization.
Because of that approach and the processes that we have put in
place, I am very happy to report that there are no pending
consults greater than three days. The National Directive states
that that requirement is seven days. So clearly, we are a best
practice within the country.
I will tell you that additionally last week, we received
our Joint Commission for-cause survey, and during the out-brief
we were verbally recognized as that practice, the consult
management practice, as being a best practice for others to
emulate.
Ms. Kuster. Thank you.
I want to turn to Dr. Kois. There is so much to discuss,
and our time is brief, so I want to make sure to focus in on
your role and your fellow whistleblowers to make sure that you
have not experienced retaliation. I think Mr. Kenney made a
really good point. If we had the appropriate processes in
place, we shouldn't be so reliant on whistleblowers. But I had
an amendment to our VA accountability bill that we just passed
in June that would provide better training and protections for
whistleblowers.
But could you just comment on your experience with that and
anything more that we could be doing to protect whistleblowers?
Dr. Kois. Sure. You know, the unfortunate situation was
that we did experience retaliation. We deal with retaliation
different ways. The way that I deal with it is I am sitting
here talking to you, and I am happy, and I am trying to treat
my patients and trying to move forward. The retaliation, the
people who did it, they don't have jobs at the Manchester VA
anymore. So in my heart, I am satisfied with my direction.
I know that Stewart Levenson received retaliation, and I
know that we have another whistleblower who is our financial
person who really had significant retaliation against him, and
they will have to deal with it in their ways.
Because of seeing other people retaliated against--I
remember Russ Pulinski and Harry Morse were retaliated
against--it put the fear in a lot of people when we first
started to bring these groups together, and in many ways it was
almost like a secret society because we were concerned that if
it got out we would be fired or canned or moved. They tried to
move me out of the spinal cord clinic even though I have 30
years' experience in it, and they tried to replace me with
someone who had none. But that didn't work, and we will just
have to keep going.
But one of the things I have to tell you, the first thing
that Dr. Shulkin said was along the retaliation issue, and he
assured us that he would not tolerate that, and Dr. Clancy here
said that in her statement, and I believe them. I think they
are making a real hard attempt not to have us feel
uncomfortable now, but the reality is that we were retaliated
against.
Ms. Kuster. Thank you. Thank you very much.
I yield back.
Mr. Bergman. Thank you.
Senator Shaheen, you are recognized for 5 minutes.
Senator Shaheen. Thank you, Mr. Chairman.
I want to go back to your comments, Dr. Kois, about the
Office of Medical Investigation. You suggested that you were
disappointed with how they operated. Can you be more specific
about your particular concerns?
Dr. Kois. Certainly. I would be glad to.
The Office of Special Counsel has a process where they
divvy up the tasks of investigation to the Office of Medical
Investigations. That investigatory board brings a report back
to them. It is then forwarded to the whistleblower. We get a
chance to rebut it. It then goes back to the OSC, and then they
ultimately adjudicate that in some fashion and issue a final
report.
Well, the Office of Special Medical Investigations, it
wasn't a real investigation. I sat there for my--initially I
wasn't on the list to be asked questions. I am the guy that
brought the 96 patients, and they excluded me. And I finally
stopped them in the hallway and said, ``Don't you want to talk
to me?'' And they said, ``Who are you?'' And I said, ``I am the
guy that got the list of the 96 patients. You may want to talk
to me.'' So they did, but they scheduled 45 minutes, spent 15
minutes introducing themselves. It came down to 18.75 seconds
per patient I was allowed to discuss, okay? What kind of
investigation is that?
Then the feedback in the report that there was no patient
harm done. But of the 96 patients, they only did two patients.
They only issued a written synopsis on two patients. They said
if you want, you can look at another 30, and everybody else is
fine. Well, if you read the Boston Globe article, they included
the 20-year vet who had the tumor and who had never been
reached as one of those who were fine. They listed the guy who
had the screw going through the nerve as fine. They listed the
guy who said he ate Chiclets for seven years because no one did
an MRI as fine.
My question is how many of those 94 patients in which they
provided no data did they really look at? So I asked the OSC to
ask for time stamps on when they went into those patients'
charts and for how long they were in those patients' charts,
and you know what? We don't have those yet. They asked for
another continuance on that.
I will tell you, if it comes out that they didn't look in
those other 94 charts, you are not going to have me quiet about
that. And if they didn't look for a meaningful time, they also
didn't ask Dr. Ohaegbulam about his letter, which is in your
files about the care.
Senator Shaheen. Pardon me for interrupting, as my time is
running. I just want to--so your concern was that there wasn't
a real independent investigation and that they didn't really
extensively review the cases that you brought before them.
Dr. Kois. Exactly. When they looked at Dr. Huq, who
fabricated notes for 10 years, they said they only looked at
three years, but based on those three years they don't think
any patient harm occurred.
Senator Shaheen. Thank you.
Dr. Mayo-Smith, Dr. Kois also suggested that he was
concerned that VISN 1 didn't really respond to the issues that
were raised by whistleblowers. Can you talk about what your
process is and whether that is a process that is designed by
the VA itself or by VISN 1 to address whistleblower concerns
when they are brought before you?
Dr. Mayo-Smith. First, let me open it up by expressing my
appreciation as well for the whistleblowers bringing forth
these concerns. It is very important for us to hear any
concerns, and we appreciate the fact that they spoke up and
that they had concerns about patient care and brought them
forward in the way they did.
My responsibility as a network director is to listen and
respond immediately to concerns. There is a steady flow of
issues that are brought into my office from patients, families,
physicians, congressionals, et cetera. And I think that it is
one of the things we learned, that whatever system we have now,
it isn't good enough.
We did look back--I did look back, of course, and look at
whatever communication that happened, and I did see that I
responded. And, in fact, I reviewed those responses with the
Deputy Under Secretary for Operations and Management in Central
Office to get his input on whether the response was
appropriate. But still, there is more to be done, I think.
That is why, on our way forward, the way forward, we are
looking at rebuilding leadership and restoring trust. As was
mentioned, this is actually a problem nationally in the VA.
Senator Shaheen. It is, and I was going to ask Dr. Clancy
if there is nationally a protocol for how leadership is
supposed to respond to whistleblower concerns. Is there a
requirement for how they should be handled?
Dr. Clancy. There is a very clear protocol, particularly
with respect to any retaliation. I also need to just say that
any health care system, VA or private sector, whatever,
actually relies on the vigilance of employees who are dealing
with patients directly or dealing with the services that affect
patient care directly to raise their hands and say we have a
problem here, you have drugs that look alike and could be
confused, or whatever the problem is. In fact, we have a
National Center for Patient Safety which fields those concerns
all the time.
All employees have an idea, and clearly we need to be
communicating this more and more vigorously, about the multiple
avenues available to them, either up through their supervisory
chain to the National Center for Patient Safety or others. I
can attest quite personally that the National Center for
Patient Safety folks, because they work for me, take that very,
very seriously, and in some instances have been able to uncover
problems where we didn't have the good fortune to have
whistleblowers making a lot of noise and so forth, so we were
able to catch that early.
It is an ongoing challenge for all health care systems, and
that human surveillance or vigilance is absolutely vital. So
the part of the story here that I find most disturbing is Dr.
Kois saying for two years he tried but wasn't effective, and
that is the piece that we need to get to.
Senator Shaheen. Thank you.
Mr. Bergman. Thank you, Senator.
Senator Hassan, you are recognized for 5 minutes.
Senator Hassan. Thank you very much, Mr. Chair.
Dr. Mayo-Smith, I want to ask a bit about the task force
you are heading up, the task force on how to deliver full
services to veterans in New Hampshire.
When Secretary Shulkin was here last month, he said--and
this is his quote--``This organization is not a full-service
organization, and that's what New Hampshire needs. So I have
charged Dr. Mayo-Smith to form a task force that will report
back to us on how we can deliver full services to our veterans
here in New Hampshire.'' Those were really welcome words from
Secretary Shulkin, but it is not the first time that we have
heard a proposal for improved services in New Hampshire, and so
I have some concerns about follow-through.
I will be paying close attention to the work of this task
force to ensure that it is not just another idea that doesn't
go anywhere. I know that Senator Shaheen and Representative
Kuster will be doing the same thing.
I also want to express concern at the fact that in what we
have seen since Secretary Shulkin's visit, the VA is already
seeming to move away from the strong full-services language
that Secretary Shulkin used. I have long felt that what we need
in New Hampshire is a full-service VA hospital. Secretary
Shulkin was clear that he wasn't prejudging whether we needed a
full-service hospital, but he was equally clear that the task
force would create a plan to deliver ``full services.''
So, Dr. Mayo-Smith, can you explain to me why Secretary
Shulkin's language about full services has been excluded from
most of what we have seen from the VA so far about the task
force? And can you recommit to us that the purpose of the task
force is what Secretary Shulkin laid out in his quote, which is
how we can deliver full services to our veterans here in New
Hampshire?
Dr. Mayo-Smith. As he stated I think in the charge letter,
we were to design services that meet the needs of the veterans
in New Hampshire. And as you state, for many years the veterans
in New Hampshire have felt that they have to travel out of
state to get services that veterans in other states can get
within their own state. And we are determined, and our goal in
this task force is to have everything on the table in terms of
what the options are, and our goal is to bring back a set of
recommendations that would allow veterans to receive here
within the state a full set of services.
Senator Hassan. Thank you for that clarification. You just
moved in your answer from talking about ``best meet the needs''
to ``full services,'' and a lot of us do see a distinction in
that language, and the charter of the task force says ``best
meets the needs'' and doesn't mention the term ``full
services.'' So what you are hearing from me and what I hear
from a lot of veterans is that we believe the only way you can
best meet the needs of the veterans in New Hampshire is to have
full services for them here in the state, as veterans in all
the other lower 48 do. Thank you.
Dr. Clancy, my office has heard from a number of veterans
and providers about concerns with Veterans' Choice, from
appointments that never get scheduled to prior authorizations
that are canceled at the very last moment. We also heard
concerns raised that the results of appointments made through
Veterans' Choice don't get communicated back to the patient's
primary care provider at the VA. These are all serious issues,
and if we are going to address improving services for veterans
in New Hampshire, then the VA must fix Veterans' Choice.
But some of the lack of coordination and communication
issues are not unique to the VA. Unfortunately, I think we find
throughout our health care system in the United States that
health care is far too siloed. In particular, we see artificial
divides between primary care and behavioral health care. We
know that behavioral health issues can have real impacts on
physical health, and vice versa.
So as you look, Dr. Clancy, at rebuilding the VA's service
capacity, how can you create a truly integrated, full-service
environment?
Dr. Clancy. Thank you so much for that question. You are
right that throughout health care what my mother used to
describe as the left hand not knowing what the right hand was
doing is a daily, hourly occurrence, and it leaves patients and
families in the middle, veterans or otherwise.
I was very, very appreciative of your comment about primary
care and behavioral mental health. Throughout our system, many
of our primary care teams have had a mental health specialist
embedded or on-site with them. I can't tell you--I am a primary
care doc. It makes a huge difference if you are recommending to
an individual that they would benefit from that kind of
assistance that you know the person and can say I work with
this person all the time. It is even better if they are right
down the hall. We are now expanding that throughout the entire
system because it is a mind-body connection. The Chairman and
others referred to the invisible wounds of war, Mr. Kenney and
so forth, and I think that is really one of the strongest
assets that we have.
Senator Hassan. Thank you.
And thank you, Mr. Chair.
Mr. Bergman. Thank you, Senator Hassan.
I claim 5 minutes for myself.
Dr. Mayo-Smith, how many years have you been working for
the VA, and when were you appointed as the Network Director for
VISN 1?
Dr. Mayo-Smith. I have been working for the VA for 32
years, and I was started as a staff position at the Manchester
VA and practiced here in New Hampshire for almost 20 years. I
spent some time in Central Office and was appointed as Network
Director nine years ago.
Mr. Bergman. And, Dr. Mayo-Smith, whistleblowers in
Manchester have stated that their concerns were sent to the
Office of Special Counsel after trying to resolve them
internally over a year ago. When were you made aware of the
issues in Manchester, and what did you do to improve operations
prior to the Boston Globe article? Essentially, why did it take
a press report to get these issues at Manchester on the skyline
to get resolved?
Dr. Mayo-Smith. Well, I think that they did bring--there
were a large number of issues raised in the Boston Globe
report, and some of them I was aware of before, and others I
had not been aware of until they were brought up by the Boston
Globe. Again, as I said, we appreciate what the whistleblowers
brought up, and we have a rather extensive and rigorous way of
interacting with the local medical centers to ensure that
problems that they bring up are addressed between the service
line leads, between site visits, between regular calls with the
medical centers.
For example, let me give one example, would be the flies in
the OR that was brought up. This was a well-known issue that
flies had been seen in the operating room. This is not a unique
problem to New Hampshire, and the medical center director there
and the medical center leadership undertook multiple efforts to
address this. They had a contract with a pest control officer,
a pest control company. They implemented the recommendations.
When that didn't work, they got another contract. Again, they
implemented the recommendations. We had an infrastructure
repair project to address this issue because of the way the
flies were entering our whole building in the walls--
Mr. Bergman. Before we use up all my time here, Dr. Kois,
how would you respond to Dr. Mayo-Smith's response?
Dr. Kois. Not real happy with it. I think that--let's talk
about the flies. You talked to the Boston Globe. They got
testimony from someone that a contractor had been in the walls
next to the OR and came across a pipe full of maggots, and they
were told to close the wall back up.
Now, this you can talk to the Globe about, but this is
something I have heard. I know for a fact that Stewart Levenson
sacrificed his career feeding negative stuff back to the VISN,
only to be treated like he was some village idiot. It disturbs
me. I also know for a fact that Stewart asked to be on the
commission and was told that he couldn't be on the commission
because he was no longer a VA employee-- this was the week
after he left--only to find out that there are four or five
other people on the commission that are not VA employees. Now--
Mr. Bergman. Let me ask--that is okay, because of the time.
Dr. Kois, in your testimony you state that the former chief of
staff, who was removed from the facility after you brought
these problems to light, has applied for a position as the
community care director at the Manchester VA Medical Center,
and has even appeared before a screening committee to hire for
that position. Is that correct?
Dr. Kois. Yes.
Mr. Bergman. Okay.
Dr. Mayo-Smith, is the VISN seriously considering hiring
him in this position despite the fact that the facility only
recently cleared up a Choice consult backlog, and he was only
removed two months ago due to the ongoing investigation?
Dr. Mayo-Smith. Perhaps I should ask Mr. Montoya to answer
that question.
Mr. Montoya. Sure. Thank you for that question. I think as
part of the recruitment process, we cast the net very early on
to try and get a physician leader. In that initial recruitment
we had five applicants. Three of them we actually interviewed.
None of those candidates were acceptable to me, which is why
that position is now reposted and we are searching for another
candidate.
Mr. Bergman. Okay, thank you. My time is getting close to
expiring here, so rather than go over, I kind of set the
standard as the Committee chair.
Ranking Member Kuster, we are going to go to a second round
here. So, Ranking Member Kuster, you are recognized for 5
minutes.
Ms. Kuster. Thank you, Mr. Chairman, and I will be timely.
I am torn between going back and going forward, so I am
going to ask a couple of questions going back and a couple of
questions going forward.
This one is for Dr. Clancy. When did the VA Central Office
first learn about the standard of care issues at the Manchester
VA? And do you know the steps that were taken by the Deputy
Under Secretary for Health Management, a Mr. Steve Young?
Dr. Clancy. Yes. So, we knew about a number of issues going
back to about January of this year. In fact, the initial Office
of Medical Inspector team went in, I believe, in February, and
started working on those issues. This was related specifically
to some of the clinical issues that Dr. Kois and his colleagues
raised.
Ms. Kuster. And what steps were taken?
Dr. Clancy. That report was sent to the Office of Special
Counsel in June, and there was also a request at that point in
time to get an additional, more in-depth review of some of the
spinal cord cases, not all. There were a couple of other issues
there as well. The Deputy Under Secretary--
Ms. Kuster. Were there meetings with the whistleblowers?
Did anyone from Washington come to meet with the whistleblowers
and hear their concerns?
Dr. Clancy. Not at that point in time, no. In fact, we were
not originally told by the Office of Special Counsel who the
whistleblowers were. From what I gathered this morning, Dr.
Kois introduced himself. So, thank you. But they couldn't have
known to be looking for him because sometimes we are told up-
front that the whistleblower says you can use their name, and
other times we are told that this individual or individuals
want to remain anonymous.
Ms. Kuster. To protect their confidentiality.
Dr. Clancy. Yes, yes.
Ms. Kuster. To make sure there is no retaliation or any
action taken toward them? Is that typically what the
confidentiality is about?
Dr. Clancy. Yes, and that is the saddest aspect of all,
that we didn't hear it sooner and we had to get to that point
in time. But that is the purpose of that confidentiality.
Ms. Kuster. Have meetings been held with the whistleblowers
since this time?
Dr. Clancy. Yes. Some senior members of my team I know have
met with Dr. Kois. I am thinking of Dr. Cox and some of his
team. There have been--I think Mr. Young met with you. I could
be wrong, Dr. Kois? No.
Obviously, Dr. Shulkin was here in early August, and we
have routinely asked--I think we speak with leadership at the
Manchester facility in the VISN two or three times a week about
what is going on, and we have heard from Dr.--
Ms. Kuster. If he is still in his role, I think it might be
useful for Mr. Young to meet with the team and just get as much
information and suggestions, because I can certainly say from
my meetings with them that they have many strong
recommendations, and they are very close to it.
Dr. Clancy. I will bring that back for sure.
Ms. Kuster. Thank you.
Just turning to quality of care issues, one of the issues
that most concerned me was the issue about transfers from the
Urgent Care Center, particularly with regard to stroke, so I am
going to address this to Mr. Montoya. What is the current
situation for patients transferred for stroke? What are the
protocols that are being used? Where are those transfers going?
And has there been sufficient training at the UCC for providers
to ensure that they are following those transfer protocols?
Mr. Montoya. Yes. Thank you for that question, ma'am. I
will tell you that out of the three recommendations that were
identified in the OIG report, there is only one now that is
open and actually will be closed, sent for closure within the
next couple of weeks, and that one is in particular the 100
percent review of all veterans who have come into the Urgent
Care who may present with stroke-like symptoms.
I am happy to report that as of last week, 100 percent of
those veterans during those reviews did follow that protocol
and were going to the--
Ms. Kuster. And just to ensure the safety of our veterans
going forward, what is that protocol if a veteran presents at
the Manchester VA for stroke?
Mr. Montoya. Yes, ma'am. So, if a veteran does present with
stroke-like symptoms, they immediately call 911 and transfer
those veterans to the nearest hospital to be able to get the
appropriate level of care.
Ms. Kuster. My time is very limited. We probably won't get
to it. I will probably have to take this for the record or the
next round, but I would like to get into the collaboration,
where things stand with Dartmouth and with the medical school
and with other providers, CMC and others. So I will yield back
and we will come back to that in the next round.
Mr. Montoya. Thank you.
Ms. Kuster. Thank you.
Mr. Bergman. Thank you, Ranking Member Kuster.
Senator Shaheen, you are recognized for 5 minutes.
Senator Shaheen. Thank you, Mr. Chairman.
Dr. Clancy, in your testimony you talked about positioning
the Office of Community Care to handle any changes to the
Choice program. As Senator Hassan and Congresswoman Kuster have
both pointed out, our office has also heard from multiple
veterans and providers who are very unhappy with the way the
Choice program is being administered. There is a separate
insurance company, Health Net, that administers that program in
New Hampshire, and we have tried to work very closely with
them, but we still see providers who go months without being
paid, we see veterans who have multiple appointments who have
been scheduled who can't see the person that they are being
directed to.
So can you talk about what you mean when you say
positioning the office? And as we look at reauthorization of
the Choice program in Washington, what does the VA think should
be done to make that better?
Dr. Clancy. Thank you very much for that question. I bet I
hear from Secretary Shulkin about this, oh, two or three times
a day. I mean, it is very, very high on his agenda.
Three years ago when the law was passed, it was, I will
say, off to a bumpy start. Over that time period we have, I
think, worked with the Congress to make 70 different amendments
to the law to touch on some of the issues all of us have heard
from veterans and providers and don't want to be there.
So we are very, very excited. You probably know that there
are seven or eight different paths for us to purchase care for
veterans in the community. You wouldn't design this from
scratch. So we have been most appreciative of the support from
committees as we work with them to come up with improved
legislation that integrates that, that has one budget for that
care, that actually uses eligibility that is determined
clinically rather than these sort of arbitrary cut points of 30
days or 40 miles, obviously a little bit different for New
Hampshire, that actually takes the clinical situation into
account, including how well is the facility providing that care
in contrast to the community, and we are looking everywhere and
have been working with experts from around the country to try
to bring in contemporary payment practices so that we can get
providers paid timely.
It clearly won't work if we don't have partners in the
community who are willing to share in this. It can work
beautifully, but you have to have those partners, and they have
to get paid, for sure. So those are really the high points, but
we are very excited about this and, again, deeply appreciative
of the support that we have been getting from Congress.
Senator Shaheen. Thank you.
Mr. Kenney, as we are looking at reauthorization, and as
the VA is thinking about the Choice program going forward, what
do you think veterans want to see?
Mr. Kenney. Well, Senator, you know, we have heard a lot of
the discussion about full-service hospital and everything else,
and I like to drop the word ``hospital'' and just go right to
full service. I think it is what the veterans expect, and it is
what they deserve.
I think as far as the Choice program, if I could borrow an
old moniker that was a wine that was served way before its
time. It wasn't ready yet. The Choice program came out on a
rocky start. It does have a lot of flaws. It does need to be
fixed.
As you know, Senator, we were at the symposium over a year
ago and we were hearing these same issues from veterans at that
time who were complaining about not being able to get
appointments from doctors, and then I believe from Mr. Anon
from the Hospital Association said the hospitals weren't
getting paid. So clearly, there are some serious flaws there,
and we would like to see those fixed, obviously.
But more importantly, the care model that Al Montoya brings
up is very important, because what it does is it puts people in
place that help veterans navigate through that Choice quagmire.
I guess the bottom line of it really is that we really need to
streamline it. We need to make it easier to use, and more
importantly we need to make it more accessible for those
clinicians here in the State of New Hampshire who stepped
forward and want to help veterans but they are afraid because
they are afraid that they are not going to get paid.
Senator Shaheen. Right.
Mr. Kenney. And I have heard that complaint many, many
times.
So there are a number of things that do need to be fixed,
Senator, and I am heartened, and I hope that part of the result
of this will be just that, to fix the Choice program.
Senator Shaheen. Me too, and I am certainly going to do
everything I can in Washington, as I know my colleagues are, to
try and make that happen.
I am also running out of time, but let me go back because,
Dr. Clancy, you, I know, in talking to Mr. Montoya, have talked
about the recruitment efforts to bring in the people that we
need here in Manchester and at the VA. How are those going,
maybe in just one word, and then I will get back to that on the
next round?
Mr. Montoya. I would say that the recruitment efforts are
exciting. Certainly, with the nurse executive position, there
were a phenomenal amount of responses from the community.
Senator Shaheen. Good. Thank you.
Mr. Bergman. Thank you.
Senator Hassan, you are recognized for 5 minutes.
Senator Hassan. Thank you, Mr. Chair.
I just want to make one note, Dr. Clancy, concerning the
Choice program. One of the most concerning things I hear from
constituents is the number of people who have been scheduled
for surgery and the night before the surgery they get a call
saying their prior authorization has been revoked.
Dr. Clancy. That is unacceptable.
Senator Hassan. That is totally unacceptable, and I just
hope you will continue to look into that in particular. I can't
imagine going through that. Some of them choose to go forward
with the surgery. Some of their providers do, too, and then we
deal with the payment afterwards. But it is just incredibly
nerve-wracking and unfair to the veterans.
I wanted to go back to the issue of how we handle
whistleblower concerns. Mr. Montoya, first of all, thank you
for stepping into a very difficult situation and working as
hard as you have been working. I hope that you agree that the
whistleblowers have done a service to veterans in New Hampshire
and across the country by coming forward with the concerns that
they have raised. They have brought forward a range of concerns
that obviously are troubling for all of us.
How is leadership at the Manchester VA ensuring that issues
brought forward by the whistleblowers are handled appropriately
and treated with the seriousness they deserve, not just this
group of whistleblowers but what is in place now to ensure that
leadership is ready, able, and nimble enough to respond to
these concerns?
Mr. Montoya. Thank you for that question, ma'am. I think
for me, first and foremost, I appreciate the whistleblowers
coming forward. I have met with nearly all of them and heard
their concerns. Additionally, my leadership team that is in
place at the Manchester VA has weekly, bi-weekly clinical and
administrative listening sessions. I am a very hands-on
director in that I also go out and practice management by
walking around to ensure that I hear from not only our veterans
but our staff members as well.
I think the one thing that really warmed my heart when I
came to Manchester was that there were roughly 800 very
dedicated staff who want to do the right thing, who want to
provide the best care for our veterans. And so it was really
harnessing that to help move the organization forward.
I think our way forward plan, which is rebuilding
leadership, restoring trust, improving care, and designing the
future and fixing Choice, each of those metrics in there was a
roadmap based on the feedback that we had heard from both the
whistleblowers as well as staff from throughout the
organization. I think I am using that way forward plan now as a
roadmap to very publicly talk about the progress that we are
making at the Manchester VA.
I think one thing that is important to note is that the
organization did not get like this overnight, and certainly
progress is not going to happen instantaneously overnight. It
will be a long road but one that I know our employees are
dedicated to making happen.
Senator Hassan. Well, thank you.
Dr. Kois, I would like to turn to you for your perspective.
You have talked about your experience as a whistleblower and
your feeling that you couldn't get the attention to the
concerns that you and other whistleblowers were raising. How do
you think the organization is doing now, and do you think
people feel that they can come forward in a whistleblower
capacity, if you will?
Dr. Kois. Since Mr. Montoya came on, for me it has been a
breath of fresh air. He has tried to be receptive, he has tried
to listen, he has tried to talk to us. The only time I had met
with the director, the previous director, was when there was a
death threat against me, and she called me into her office and
told me that I could fill out a Freedom of Information Act to
get my death threat. Now, how many people would say that to
someone? I have to fill out a Freedom of Information Act to get
my own personal death threat?
Al stops in my office. I can't play video poker anymore
because he is going to open the door and say, ``What's up?'' I
like that. I like seeing him. He has been receptive to us, and
I think it is a good direction. But as he said, it took years
to get this way. It is going to take a while. We are not over
it. We cannot sing Kumbaya and everything is great. We have to
work together.
But you know what? I am happy to work with Al. I am happy
to work with Brett. And I love Shulkin. Shulkin, to me, was a
breath of fresh air, and I think that we are going to have to
all work together on this. Community partnering is what I am
excited about, and I would like to tell you there are some
great partners out there. We are working with Larry Gammon in
Easter Seals. We are working with Dean Kamen, the inventor, and
we have some exciting things.
My hope is that from this catastrophe springs a new
beginning and really an exciting time for our VA in Manchester.
Senator Hassan. Thank you.
And, Mr. Chairman, my time is up.
Mr. Bergman. Thank you.
I will claim my second round here of 5 minutes.
Dr. Clancy, has VHA completed a review of the deficiencies
at the VISN that allowed these problems to occur in Manchester?
Dr. Clancy. We have not. Right now what we are really
focused on is what happened in the clinical care processes. I
would be happy to take that for the record. I know from
extensive conversations with Dr. Mayo-Smith that he has looked
into this, and the question is how much of that got to him and
so forth.
I will also say several of you noted the insights and
implications for other VAs. This is something that all of our
network directors are working on right now, trying to figure
out what are our vulnerabilities and, very importantly, how do
we know, if people bring this up, do we hear them. And if we
are not hearing anything, does that mean that there is not a
problem? That, I think, is the worry that we think about a lot
in our system.
Mr. Bergman. Thank you.
Dr. Mayo-Smith, we know that there are several reviews
being conducted here at the Manchester VA. What is being done
at the VISN level to improve communication and operations
management?
Dr. Mayo-Smith. We are always seeking to make improvements,
and what we have done in this particular situation is, as all
the reviewers from Washington have come and gone, as I have had
an opportunity to speak at length with many of the
whistleblowers, as had Mr. Montoya and other leaders from both
the VISN and national, we are pulling together Mr. Montoya, our
quality manager, and one of the other medical center directors.
I have asked them to sit down and say what are the lessons
learned from this incident.
We are going to have our own internal stand-down to pick
the three things that really we see went wrong in terms of
process at Manchester and go around the network to the other
seven medical centers and really go have a stand-down, a deep
dive, and make sure that we address those issues. This is going
to be done. We have a face-to-face meeting with the leaders in
September. We will review it at the end of this month, and then
in October we have a large leadership meeting and we are going
to report back after that has been done.
We have been doing this at the national level as well. This
is something that I have been an advocate for, that we take
lessons learned when things go wrong at one medical center or
another medical center across the country and share them among
the network directors so we can be a learning organization and
make improvements when something goes wrong or something goes
off kilter in another area.
Mr. Bergman. Dr. Mayo-Smith, what is the current duty
status of the former director and chief of staff for
Manchester?
Dr. Mayo-Smith. The former director has been detailed to
the network office, detailed to myself, and I have assigned her
to work with the strategic planner. And Dr. Schlosser, the
former chief of staff, has been detailed to work with the chief
medical officer.
Mr. Bergman. For how long?
Dr. Mayo-Smith. Until the investigations that are being
undertaken by the Office of Accountability and Whistleblower
Protection are complete and they have made a decision on what
the findings were with regard to the performance and conduct of
these two individuals.
Mr. Bergman. When should we expect those investigations to
be completed?
Dr. Mayo-Smith. We are hoping that they will be done very
soon. We constantly check, and I have been told sometime--two
to four weeks is what I have been told, but sometimes they find
new things during the investigation.
Mr. Bergman. Dr. Clancy, in your written testimony you
state that the VA plans to create a Subcommittee of VA's
Special Medical Advisory Group, which would report to the VA or
on the VA care delivery model for the New Hampshire veterans by
January 2018. Is that the same group as the task force that was
stood up last week to perform what appears to be the same
function which includes Dr. Mayo-Smith and Mr. Kenney?
Dr. Clancy. No. We have a standing advisory group for the
entire department that focuses on medical issues. It includes
very prominent leaders from U.S. health care, a very, very
helpful function to us, giving us feedback, advice,
recommendations. They meet in public, as do all Federal
advisory committees.
The task force that Dr. Mayo-Smith and Mr. Kenney are
leading--and thank you for that, Mr. Kenney--was initially
conceived of as internal VA people from outside the network and
some inside. For a variety of reasons, primarily I believe
because the focus was on New Hampshire veterans, it was thought
that it would make a lot more sense to have the New Hampshire
Hospital Association there, to have a New Hampshire veteran, to
have Mr. Kenney, and so forth. So that cast it in the light of
a public advisory committee. So it is a Subcommittee of that
larger group, but ultimately it comes right back to the
Secretary, and he is impatient and wants to hear from them
sooner than later.
Mr. Bergman. Okay, thank you.
I see that my time has expired, and we are going to proceed
to a third round here.
So, Ranking Member Kuster?
Ms. Kuster. I am going to yield to Senator Hassan, who has
to catch a plane.
Mr. Bergman. Very well.
Senator Hassan. Thank you very much, Representative Kuster.
And again, Mr. Chair, thank you so much for being here in New
Hampshire. We are grateful for the bipartisan work that you and
your Committee and the Ranking Member have done and continue to
do.
To all the witnesses, thank you again for being here and
for your commitment to our veterans.
One of the things that I also want to ensure that we focus
on is that we are meeting the needs of our Nation's women
veterans. That is why I have joined with a bipartisan group of
colleagues in introducing the Deborah Sampson Act to address
gender disparities at the VA. The bill would expand peer-to-
peer counseling, improve the quality of care for infant
children, increase the number of gender-specific providers and
coordinators at VA facilities, and improve collection and
analysis of data regarding women veterans.
Dr. Clancy's testimony notes that the Manchester VA has
recently hired a women's health medical director and a women's
veterans' program manager. First of all, I want our women
veterans out there to know that these hires have been made and
that there are services accessible to them. But, Mr. Montoya,
could you elaborate on the role of these new hires? What are
they going to do?
Mr. Montoya. Sure. Thank you so much for that question. I
will tell you that they will do what all other teams do in
primary care, and they will make sure that our female veterans
are taken care of, and the quality of care that they receive is
top-notch.
I will tell you that the women's veteran clinic was
actually in one of the areas that was damaged by the flood. It
is one that we hope to get back open sometime around the middle
of November, and then we will be able to continue that clinic
there.
In the meantime, they are actually being seen down in
primary care, where we do have space, by our dedicated female
veteran's team.
Senator Hassan. Well, thank you.
Dr. Clancy, I wanted to turn back to something you said,
just because I am always trying to understand the VA's
terminology when you talk about progress you have made, which I
am appreciative of. But when we talk about patient consults and
the fact that there was a backlog in Manchester and that we are
now catching up, when you say that 95 percent of pending
consults are being taken care of in two days, what does ``taken
care of'' mean?
Dr. Clancy. It means that an appointment has been made and
that we will then follow through to make sure that we get the
information back, because that is the all-important care
coordination that you were talking about.
Senator Hassan. Okay. Thank you for that.
And when you mentioned the independent review of the cases
that Dr. Kois and others have brought forward, it is a peer
medical review; correct?
Dr. Clancy. Yes.
Senator Hassan. Does that include interviews of patients
and clinicians?
Dr. Clancy. Initially it is going to include a very
rigorous investigation of charts, including medical images and
so forth, and it may be that it will include interviews of
clinicians and patients, particularly for some of the
longstanding cases that Dr. Kois had mentioned. But right now
we are focused on getting them that initial round of
information. It is about 100 cases, and some are quite old. I
mean, there are a lot of records to go through, so we have been
busy getting them the information to do that.
Senator Hassan. I understand that. I would urge you to
think about the fact that if part of the concerns that have
been raised is that the records themselves do not accurately
reflect the care or the symptoms or the range of possible
clinical diagnoses, that just doing a chart review may not be
enough. I think one of the concerns that I have heard from the
whistleblowers is that by stopping at the charts, the VA really
couldn't see what it needed to see. And I don't want to put
words in the whistleblowers mouths, but that is just a concern
I have heard. So I would urge you to empower the independent
review committee to really reach deep if they need to.
Thank you very much, and thank you again, Mr. Chair.
Mr. Bergman. Again, thank you, Senator Hassan, for being
with us today, and safe travels back to D.C.
Senator Hassan. Thank you.
Mr. Bergman. Senator Shaheen, you are recognized for 5
minutes.
Senator Shaheen. Thank you. I also have a flight. Mine is a
little later than Senator Hassan's, so I appreciate the
opportunity to go next.
I guess this is for you, Dr. Mayo-Smith, because as chair
of this new task force that has been created, you are charged
with studying the possibility of providing full services.
Whether we call it a hospital or full services, as Mr. Kenney
did, the idea is how do we make sure our veterans get the care
they need. How do you go about studying that? What do you
expect the task force to do? Can you be a little more specific
in terms of what actions you expect the task force to take?
Dr. Mayo-Smith. Certainly. So we have laid out our plan,
and we are going to be approaching it from several points. One,
we are doing an extensive review of workload and demographic
data and projections into the future.
Second, we are looking at--we are going to be a pilot or
the first wave of the Office of Community Care doing a
community market survey, something they are going to do across
the country. They are going to come here first. What resources
are available in the community? It varies from place to place.
We are going to be looking at the infrastructure. We have
already had a consulting architect come in with a team to look
at this last week.
Probably the most important part is we are doing a series
of clinical service line reviews which the leads, the service
line experts--primary care, mental health, rehab, geriatric
medicine, surgery and radiology--they are going to be working
with the staff at Manchester, review the current services and
what could be the options for the future services.
So an example, with mental health, what about a day
hospital? What about an inpatient hospital? What about a
substance abuse treatment rehab program? Those are programs
that other VAs have. Would it be a good fit? Is it needed by
this population? Where are the patients getting it now?
Then we are going to have a series of meetings. A lot of
the other thing is stakeholder input. We have already started a
whole series of focus groups with veterans, with employees,
with stakeholders. We are meeting with your staff. We are
meeting with the whistleblowers, et cetera, to get input, what
do they want, what do they need, and we are going to put this
together with a series of meetings to come up with options and
then make recommendations.
It will go to the Special Medical Advisory Group, which is
excellent because they are some of the top leaders in health
care, and then they will present them to the Secretary. I
encourage this group to hold us accountable to getting these
recommendations in and for following through.
I am a practicing clinician in the VA. I have worked at
Manchester. I see patients. I want to make sure that the
practitioners and the patients at Manchester--I am determined
that they get excellent care and that these changes that are
needed are made.
Senator Shaheen. Thank you.
My last point is not really a question, but as I looked at
the other testimony that was submitted before today, Mr.
Chairman, there were some very serious concerns raised and
allegations that had to do with the dental program, with the
electronic wait list, with the nuclear camera and its impacts
on radiology and cardiology. So maybe for you, Mr. Montoya, as
you are going forward, but certainly also for Dr. Clancy, I
hope these will also be looked at very carefully and responded
to.
I have also had concerns raised about pharmaceutical
protocols. So I would just urge that as you are addressing
those, that you also share with us and with the public some of
the changes that have been made so people understand that there
is an effort to respond to the issues that have been raised.
So again, Mr. Chairman and Ranking Member Kuster, thank you
very much for holding this field hearing. Thank you all on the
panel for testifying.
Mr. Bergman. Thank you, Senator, and thank you for joining
us today.
Ranking Member Kuster?
Ms. Kuster. Thank you, Senator Shaheen, and safe travels.
Thank you for being with us.
Well, I am glad that Senator Shaheen brought up the other
issues because, honestly, we could be here all day. We will
stay in close touch with Mr. Montoya and with Dr. Clancy and
Dr. Mayo-Smith. Again, I want to thank Mr. Kenney for your role
in this and for being a conduit so that veterans will be heard
throughout this process. Ultimately, at the end of the day, it
is their experience that counts.
Two quick questions. How does a situation occur where 3,000
consults are on hold and you don't know about that? Either Mr.
Mayo-Smith or Dr. Clancy, what are the metrics? Isn't there a
way, isn't there a dashboard that you would be aware of the
backup? Because I certainly know from repeated meetings with
Danielle Ocker that there was a problem, there was a problem
with the Choice program that they weren't being approved, that
financially--we haven't gotten into it today, but I know one
hospital in New Hampshire that is owed $3 million. How can we
ask our community hospitals to step up and care for our
veterans when they are owed $3 million? That is real money
where I come from.
Could you respond on the metrics and how you weren't aware
of this? How do you get a backup of 3,000 consults?
Dr. Mayo-Smith. Well, normally the--well, the Choice
program has been problematic from the beginning. We have been
working hard addressing it. At the network, in our network, we
have a weekly call with our business office manager in each
medical center. We have numerous reports that we track this.
In Manchester, we would expect about 3,000 consults to be
in process at any given point in time, and we found, as was
mentioned, 3,900 that were, so there was a backup. And it was
very clear that the local business office was not--I mean, it
appeared--as far as we could tell, it appeared that some of
these patients were being seen, but the consults were not being
closed, and in other cases the consults may have been closed
but the patients weren't being seen yet. So the data that we
were getting did not appear to be entirely accurate.
Ms. Kuster. Do you think that the decision that has finally
been made--this is something that I have been pushing since I
first went to Congress, five years? I can still remember the
very first hearing about the electronic medical record. Do you
think the decision to go to a new electronic medical record
that is a commercial product, off the shelf, we can now
communicate DoD to VA, we will be able to communicate with our
community providers, and will this help this situation?
Dr. Clancy. Yes. I can say that we are already working with
our community partners to accelerate a path to electronic
information now. But having one platform for all of VHA will
make a huge difference. There are a lot of clunky pieces in our
system. You probably hear hospitals tell you--we have EPIC, and
so do they, but they don't talk to each other. Well,
essentially that is what we have internally with our home-grown
system. So we are very, very excited about the path forward.
Ms. Kuster. I don't mean to cut you off. The time is short.
But I do want to make the case for VA Central Office to
recognize that New Hampshire is in a different situation
without a full-service medical hospital. We are over-reliant on
our community care, and that was not backed up in the budgetary
decisions. Frankly, I think part of what was going on was
triaging and bureaucratic hurdles for the veteran because the
money wasn't in the budget, and that is a bigger issue that we
need to tackle.
I also just want to mention that I believe, having toured
the women's facility up at White River Junction, that taking
that approach of a new facility with a separate entrance and a
real focus on women's health for our veterans is critical. I
think Manchester has fallen behind the times, frankly, and that
this is an opportunity. Certainly I can tell you, you will have
the strong support of the Federal delegation to back you up
with that, and if it takes additional funding or whatever is
necessary.
But I do want to put on the record a relatively new
allegation from a whistleblower about a female veteran that was
sexually assaulted, and hopefully you are aware of that. If
not, our office will bring it to your attention.
This is critical, and it is way past time for our women
veterans to get the care and the respect that they need.
I will continue to work with everyone. I appreciate,
General Bergman, you coming to New Hampshire and making the
trip. I am proud to be working in a bipartisan way, and we will
hold the Administration's feet to the fire.
Again, thank you to the whistleblowers for bringing these
issues to our attention, and I yield back.
Mr. Bergman. Thank you, Ranking Member Kuster.
The final question before we do a little closing here. Dr.
Clancy, you stated in your opening comments that two suicide
prevention coordinators had been added to the staff. How long
had that request for additional positions been in the system?
Dr. Mayo-Smith. I would have to take that question for the
record and give the exact date back to you.
Mr. Bergman. Okay, because obviously the need for suicide
prevention coordinators is not something that just popped onto
the screen, okay?
Dr. Kois, VA's testimony states that an independent review
to be conducted by Lumetra Health Care Solutions has been
requested regarding the myelopathy and OMI investigations. You
and many of the other whistleblowers have been calling for an
independent review for some time. So are there any specifics
that you would like to see as part of the charter for this
review?
Dr. Kois. Sure. We don't think that the medical records are
sufficient to have this review. Part of the issue with
myelopathies is it occurred in the absence of treatment, not
because of necessarily a bad treatment. So because of that,
especially in light of the fact that for 10 years the medical
records were fabricated, to look at medical records is just
incorrect, it is just insufficient.
What we feel needs to happen, is that you actually have to
go take a history and examine the patients. You have to hear
from the patients, because one of the things that stood out to
me is that I would ask the patient did the doctor offer
surgery, and the patient would say, well, the doctor said I
would die if I had surgery. I would go back to the chart and
the chart would say the patient refused to have surgery. But if
you are given an option that you are going to die if you have
surgery, it is sort of a no-brainer that you are going to say,
no, I don't want to have surgery.
So there was a big disconnect between what was showing up
in the charts and what was happening. We also had Dr. Huq, who
was fabricating notes for 10 years. So I think the minimum is
you have to go back, call these 96 patients, get a history from
them, you have to have someone examine them.
The other thing you need to do is you have to assess their
level of disability. You can have spinal stenosis that develops
mild symptoms of myelopathy and it is not a surgical case, but
by the time they reach the point that they are in a wheelchair,
they are in an electric wheelchair or they are in diapers, you
have a problem.
If you look at the durable goods that were ordered for
these patients, there were 20-some people who were in electric
wheelchairs or manual wheelchairs. The numbers I will have to
get to you. There were a number of them that were in diapers.
There were a number of them that had in-dwelling catheters or
cathed themselves because their bladder was not functioning.
There were a number that had adaptive equipment to eat and feed
themselves and to toilet themselves.
Those cases were let go too far. You shouldn't reach that
point. But the only way you can come to that realization is to
ask the patients, and then to get a list of the durable medical
goods. If you get the list of the durable medical goods, it
just pops out at you because the list was this thick in those
96 patients, and we are talking 50 or 60 items per page.
So if you just look at the chart, it is not enough. And if
you just have an outside company looking at the chart, it is
not enough. You really have to go back and look at the whole
thing.
You also should talk to Dr. Ohaegbulam. He is the surgeon
that made the statement that these cases resembled cases he saw
in the third world. I would get his opinion on that.
Interestingly enough, Al Montoya and Brett Rusch have just
brought Dr. Ohaegbulam on board, and he is now going to be one
of our consultants. He is a great doctor. People should ask his
opinion of what happened.
Mr. Bergman. Thank you very much.
I will conclude my questions at this point, and we are
going to move to our closing statement.
I truly want to thank all of our witnesses for
participating in today's hearing by making the effort to come
here, by making the articulate statements that you did. I
believe we have brought some very, very important and highly
prioritized issues to the forefront.
You are now excused.
I would especially like to thank Dr. Kois for joining us
today and for being one of the main focal points for the
whistleblowers who brought many of these issues to light.
Without the involvement of conscientious whistleblowers at the
Manchester VA Medical Center, many of these problems would
likely still be unknown to the New Hampshire veterans,
Congress, and the rest of our country.
As the Subcommittee Chairman and a veteran, I am very
concerned about leadership failures and deficiencies that have
existed in Manchester and have been allowed to be compounded
for too many years.
It was also very clear that there was no sense of urgency
within the VISN to address these problems. Dr. Mayo-Smith, you
stated, quote, ``My responsibility is to listen and respond,''
end quote. It should not take a news report or a congressional
hearing for VA leadership to respond to veterans' and
employees' concerns. As VISN director, your job is to lead
proactively, not reactively.
VA has pledged publicly to make great improvements in
quality of care, infrastructure, and other critical areas, but
these improvements must also include better oversight and
management at the VISN level and within VHA.
I hope that the discussion we have had today will help
instill in VA that so necessary sense of urgency that I think
we all agree is needed to bring about the systemic changes
still needed within the VA New England Health Care System.
I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and to
include extraneous material.
Without objection, so ordered.
I would like to again sincerely thank all of our witnesses
and audience members for joining in today's conversation.
With that, this hearing is adjourned.
Ms. Kuster. I just wanted to add, thank you to the National
Guard for hosting us. This is a great facility and we very much
appreciate it. Thank you.
Mr. Bergman. Thank you.
[Whereupon, at 12:20 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Dr. Carolyn Clancy
Good morning, Chairman Bergman, Ranking Member Kuster, and Members
of the Subcommittee. Thank you for the opportunity to participate in
this hearing to discuss VA's response to the concerns raised at the
Manchester, New Hampshire VA Medical Center (VAMC). I am accompanied
today by Dr. Michael Mayo-Smith, Network Director for VA New England
Healthcare System (Veterans Integrated Service Network (VISN) 1), and
Mr. Alfred Montoya, Jr., Acting Medical Center Director at the
Manchester VAMC. I would like to specifically note the appreciation
that we have for Mr. Montoya stepping forward into a tough situation
and handling it admirably.
First, let me begin by saying that VA appreciates the actions taken
by whistleblowers when it comes to safeguarding care for our Veterans.
We are committed to always protecting those whistleblowers from
retaliation. VA has and will continue to take immediate action when
responding to whistleblower concerns at any VA facility across the
country. The Office of the Medical Inspector (OMI) and the Office of
Accountability and Whistleblower Protection (OAWP) were sent to conduct
a top-to-bottom review of the Manchester VAMC. In response to the
allegations, the Secretary rapidly recognized the need for a new
leadership team. We look forward to this opportunity to build trust
between VA and our Veterans and to keep Congress up-to-date on our
progress.
Our focus in Manchester is now on the way forward and ensuring that
high quality and timely access to care is the standard in all aspects
of Medical Center operations. Currently, the Medical Center is
executing a plan that focuses on five key areas which include the
following: rebuilding leadership, restoring trust, improving care,
fixing the Veterans Choice Program's local operations, and designing
the future.
One focus of the whistleblower concerns was the lack of consistent
leadership in key positions at the Medical Center. Currently, we are
actively recruiting for the Medical Center Director, Chief of Staff,
Nurse Executive, Chief of Medicine, Chief of Surgery, Chief of Primary
Care, Director of Urgent Care, and a physician leader for the newly
created Office of Community Care. In order to attract the highest
caliber candidates to these key positions, we are recruiting
nationally.
Second, we are also working on restoring the trust of our Veterans,
staff, and community stakeholders. Medical Center leadership has taken
swift action to ensure that all members of the Medical Center,
including clinical staff, are included in key decisions. VA acted
swiftly and immediately by asking OMI and OAWP to review the
allegations raised in a Boston Globe article. Additionally, the
Secretary directed a top-to-bottom review of all aspects of the VAMC's
operations, which provided key action plans for improvement. We also
requested a non-VA review, conducted by Lumentra Healthcare Solutions,
a peer review network, of our myelopathy cases and the above-mentioned
OMI investigations. Finally, there has been consistent, structured
public reporting and listening sessions with Veterans, staff, and
community stakeholders to discuss progress at the Manchester VAMC.
Our third area of focus is improving timely access to care. To do
this at the Manchester VAMC, we have committed over $5 million to
hiring additional staff. This includes several key positions on the
cardiology staff and two new patient-aligned care teams (PACT) for
Primary Care. In addition, we have accelerated community and academic
partnerships to support the Medical Center. In a first-of-its-kind
collaboration with a private hospital in Manchester, we have seen
dozens of Veterans for endoscopic procedures with VA providers using
the hospital's space. We are well underway to securing a second
arrangement for general surgery, orthopedics, interventional pain, and
urology procedures. In addition, we have successfully recruited an
academically affiliated cardiologist who started last week. The Acting
Chief of Staff is working with Dartmouth Hitchcock to discuss physician
leaders in Manchester securing Dartmouth College affiliations. We are
looking to open an accredited rehabilitation program for chronic pain
and purchase needed equipment for surgery. We have also restarted
nuclear medicine tests at the VAMC with the goal of adding stress tests
by October. We have successfully hired two suicide prevention
coordinators, a Women's Health Medical Director, and a Women Veterans
Program Manager. We are also working hard to ensure that all areas
affected by the flood at the Medical Center are open and operational by
the end of December 2017.
Using VA providers and staff to perform outpatient procedures at a
number of our community providers has enhanced the experience that our
Veterans in New Hampshire receive. However, our Veterans, providers,
and community stakeholders have made us aware of the serious work
needed to improve the Veterans Choice Program, which is why our fourth
focus is on enhancing the experience of all involved in this Program.
On July 26, 2017 we created a new Office of Community Care in
Manchester that consists of over 30 staff, including 17 new positions,
dedicated to ensuring our Veterans have assistance in navigating all
aspects of Care in the Community. This Office processed and cleared a
backlog of approximately 3,300 pending consults. With a change in
process, 95 percent of all pending consults are being taken care of
within 2 business days. Additionally, we have taken a proactive
approach with our community providers and assisted in ensuring that
bills from our providers within the Veterans Choice Program network and
our community care providers are being processed in a timely manner. We
have established routine calls with our Veterans Choice Program
network's field operations staff, embedded a Veterans Choice Program
network representative full-time within our staff, and fostered a
relationship of collaboration. We are positioning the Manchester VA
Office of Community Care to be able to handle any changes to the
Veterans Choice Program in the future.
Finally, Secretary Shulkin will be creating a subcommittee of VA's
Special Medical Advisory Group (Advisory Group), one of VA's Federal
advisory committees, to make recommendations to the Advisory Group on
the future VA care delivery model for New Hampshire Veterans. The
subcommittee membership will consist of strong representation from New
Hampshire Veterans, VAMC staff (including representation from
whistleblowers), regional and national subject matter experts, and
leaders of the New Hampshire hospital and provider communities. Under
the direction of the Advisory Group, the subcommittee will undertake a
careful review of data and develop innovative options for improvement.
Its goal will be to provide recommendations to the Advisory Group
regarding the future vision of what VA must do to best meet the needs
of New Hampshire Veterans. The subcommittee will take the grave
infrastructure issues at the Manchester VAMC into account when
developing its recommendations to the Advisory Group. The subcommittee
will make recommendations to the Advisory Group, and the Advisory Group
will in turn make recommendations to the Secretary, through the Under
Secretary for Health, by January 2018.
We look forward to this opportunity for our new leadership to
restore the trust of our Veterans and continue to improve access to
care inside and outside VA. Our objective is to give our Nation's
Veterans the top quality care they have earned and deserve. Mr.
Chairman, we appreciate this Subcommittee's support and encouragement
in identifying and resolving challenges as we find new ways to care for
Veterans. My colleagues and I are prepared to respond to any questions
you may have.
Prepared Statement of William Edward Kois, MD
Mr. Chairman and Members of the Committee,
My name is Ed Kois, and I am a VA physician at the Manchester
Medical Center. I have worked there since 2012 in the Spinal Cord
Clinic and in the Pain Clinic. Even though I receive a paycheck through
the VA Agency, I consider myself an employee of the Veterans of our
state. It was because of this and because of my concern over their
care, which I had deemed extremely inadequate, that I spoke out, first
by going through and within the VA system.
After almost two years of utilizing all avenues available to me,
and receiving no satisfactory solutions, I spoke to my colleagues and
discovered that many of them had similar issues with management and
patient care. Because of my fear of further harm occurring to our
patients, I contacted an attorney who assisted us in being heard by
Senator Shaheen and Representative Kuster, and then the process began
with the Office of Special Counsel. Our Whistleblowers are comprised of
doctors, nurse practitioners, nurse anesthetists, as well as a Business
Service Line Manager.
The Boston Globe publication on July 16, 2017, regarding the
Manchester Medical Center, almost one year after filing our
Whistleblower Complains with the Office of Special Counsel, finally
brought the light of day to our serious concerns about the care and
treatment of the Veterans, as well as the sub-standard facilities and
equipment found in Manchester. The details are well chronicled in this
article, as well as all of the Whistleblower filings on record with the
Office of Special Counsel.
The problems that are seen at the Manchester VA, however, are not
unique to just this facility. I believe the same issues can be seen
nationally.
The publication of the Boston Globe article resulted in a meeting
with Dr. David Shulkin, the Secretary of the VA, on August 4, 2017,
where he met with eight (8) of the Manchester VA Whistleblowers. Dr.
Shulkin listened to us, and quickly acted to remove the three (3) top
administrators, who were the focus of many of our complaints. Of note,
however, it was not just these three (3) individuals, but also the
entire operational system in Manchester that had led to the problems
elucidated by myself and the other Whistleblowers.
As our attorney alluded to in her letters to Senator Shaheen and
Representative Kuster, the inverted pyramid structure of operations at
the Manchester VA, wherein there are relatively few, if any, clinicians
in positions of power making patient care decisions, as well as
decisions regarding needed equipment and purchase of replacement
equipment, caused a disconnect between the providers of the care and
the bureaucrats who controlled the decisions. This disconnect was
largely responsible for the substandard treatment and care of my spinal
cord patients, that led us to where we are now.
Dr. Shulkin named an Acting Medical Director, Alfred Montoya, and
Dr. Rush, as Acting Chief of Staff; however, this temporary situation
has not changed the corporate culture from the nurse managers below Dr.
Rush and Mr. Montoya. Conditions are still unacceptable in the OR and
other practice areas where managers who were put in place by Carol
Williams, who was removed from her position by Dr. Shulkin on August
4th. In fact, although Dr. Shulkin removed Dr. James Schlosser as Chief
of Staff on July 16, 2017, he has applied to be the new Community Care
Director at the Manchester VA, and appeared before a screening
committee on September 7, 2017. How can this happen?
Some things have started to improve. I have recently been asked to
participate in the search committee for a new Chief of Staff. It would
be advisable to put other providers on the search committee for the new
Medical Center Director, and the new Chief of Nursing. Apparently,
these positions cannot be filled until the current Medical Director and
Chief of Staff are formally removed from their positions. It has been
two (2) months and they still have not been removed, and so there has
been no outside advertising for those positions.
As I said above, the issues with the administration and operational
matters at the Manchester VA are not unique to Manchester; that a
remodeling of the Manchester VA operation system can be used as a
template for other small VA Medical Centers in this country.
Problems such as the over-reliance on metrics, the incredible
bureaucratic quagmire that has existed for decades need to be changed.
We must move in a direction that mirrors the public sector hospitals,
where clinicians are on the governing boards, and provide a balance to
the bean counters when they lose sight of the true mission of the
medical facility, which is to provide excellent patient care to our
Veterans.
Prepared Statement of David J. Kenney
Subj: Testimony on the Manchester, NH VA Medical Center
Mr. Chairman and distinguished committee members. It is an honor to
submit this testimony as current Chairman of the NH State Veterans
Advisory Committee. Our committee is comprised of 19 veteran service
organizations as well as advisors from a number of state agencies in
New Hampshire that provide services to veterans and their families. I
should also state for the record that I am a 40 year Navy veteran and
currently do not obtain care through the Manchester VA.
As part of the New Hampshire veteran leadership, I have been
involved in New Hampshire veteran's issues since 1992 and a member of
SVAC since 2001. In the 16 years on SVAC, I've heard briefings on
various isolated complaints with the VA in general and on individual
challenges with access to care. However, the revelations by the Boston
Globe article were appalling. The article exposed an alarming level of
systemic breakdowns with areas of the VAMC facility and alleged lack of
commitment by administrators to fixing the issues that were cited by
the whistleblowers.
Since the Boston Globe article has come out, I have personally
participated and/or observed a number of meetings related to the VA in
Manchester, including the public meeting held by the whistleblowers to
air their concerns, unfiltered. I am personally pleased the
deficiencies have been exposed and believe this exposure offers a great
opportunity to not only fix issues at the VAMC in Manchester, but
potentially develop some valuable ``best practices'' which could be
deployed in other VA medical facilities around the country.
The VA in Manchester has been lauded by many veterans for the
superb quality of care they receive there. What remains a significant
challenge is the access to care, ensuring the best technology is
available for care, access to primary care physicians, and when needed
the CHOICE program. Interim-Director Al Montoya has advanced a number
of significant improvements to solving many of the deficiencies
discovered since reporting to the VAMC in July 2017. Director Montoya's
precise and methodical approach to discovering key areas of lag or poor
function have allowed him to create a comprehensive plan to make
immediate changes and improvements to the medical center. Included in
that plan is rebuilding leadership and increasing staff hiring in
mental health, nursing, surgery and patient services. A key element of
these improvements is creating a more robust Office of Community Care
modeled after the successful pilot program he created for North Country
veterans. He has been instrumental in increasing staff in key areas and
working quickly to hire new leadership for departments that have senior
vacancies. Despite the added challenge of a water main break at the
facility that affected several floors, Director Montoya has been
working diligently with contractors to get services affected back on
line as quickly as possible.
Access situations, like appointment requests bouncing back and
forth from CHOICE to the VA are totally unacceptable. The simple fact
is veteran's lives are at stake. This is not just a trite statement but
one that has been borne out in facilities around the country. In
addition to the VA facilities needing to be raised to superior
standards, we need a full funding commitment to the CHOICE program.
CHOICE offers a flexible alternative to veterans who live long
distances from a VA facility. Transportation can often be a challenge
for veterans, so having a local care option is crucial. In addition,
streamlining the access to CHOICE care by expediting approved doctors,
and timely payments from the CHOICE program to those providers who sign
on in good faith to serve the veteran population.
While significant progress has been made, more needs to be done to
prevent this type of calamity from reoccurring. I believe it is
imperative that new leadership take the form of someone who will create
an environment of trust from both staff and patients alike.
Accountability and a pursuit of excellence should be a daily routine.
Prevention of issues like ill-equipped clinics or operating rooms can
only occur when staff can raise those concerns confident that the
administration will listen and act to address those concerns honestly.
When patient safety is at stake, there can be no compromise. In the
final phase of this process, the culture of the VAMC needs to change.
In my experience, corporate culture refers to the shared values,
attitudes, standards, and beliefs that characterize members of an
organization and define its nature. The right leadership will set the
standard for that culture at VAMC Manchester.
I have recently been given the privilege of serving as Co-Chairman
on Secretary Shulkin's Task Force to review and make recommendations
for improvements at the VA Medical Center in Manchester. Part of our
charter is ensure that we think creatively and entertain all reasonable
options that would be most prudent to implement and send those
recommendations to Secretary Shulkin for his consideration. It is my
sincere hope that our recommendations will get the full support of the
VA Secretary and Congress' financial backing. As we go through this
process, we will be closely monitored by the veteran population here in
New Hampshire and around the country. We cannot fail them any longer -
their lives may depend on it.
Thank you for your consideration of this testimony. I remain at
your service to answer any questions you may have.
Respectfully Submitted,
David J. Kenney
Chairman
The Veteran Advisory committee is comprised of senior leadership
from American Legion, Veterans of Foreign Wars,
Disabled American Veterans, Vietnam Veterans of America, Military
Order of Purple Heart, Reserve Officers Association, The Retired
Enlisted Association, Military Officers Association of America, The Air
Force Association of New Hampshire, Air Force Sergeants Association,
The National Guard Association of New Hampshire, Marine Corps League,
Combat Veterans Motorcycle Assoc., Rolling Thunder, Catholic War
Veterans, and the New Hampshire Army Retiree Council, The NH Veterans
Association and Col Cross Chapter-Association of US Army
Statements For The Record
Erik J Funk MD FACC
Statement to House Committee on Veterans Affairs Regarding
Deficiencies at the Manchester VA Medical Center.
Manchester VA Medical Center Manchester, NH
Mr. Chairman and members of the committee.
I appreciate the opportunity to submit this statement regarding my
observations and efforts (as well as others) to maintain and improve
Cardiology services at the Manchester VA Medical Center. What needs to
be conveyed today is that the VA Manchester is currently an absolutely
and unequivocally a broken hospital system. A system that was devoid of
adequate funding, is culturally dysfunctional and lacking in qualified
administrators. The question is whether our hospital can be salvaged
from the dustbin? I am a believer however that the Manchester VA can
and must be an accessible and quality provider. To be sure our nascent
Task Force committee project demands a comprehensive plan and follow
through. This newly developed master plan and eventual end product
should be guided by talented directors and chiefs of services who are
in turn accountable to employees, providers as well as to the veterans
we serve and finally to the Secretary, Dr. David Shulkin who has
thankfully endorsed this effort.
I received my medical degree 42 years ago and have practiced
Cardiology in the private sector for over 30 years. I joined the VA in
December 2013. Prior to my current government service work, I was in
private practice involved in outpatient and inpatient invasive and non-
invasive Cardiology services. I was very fortunate to have participated
in the development of Cardiac services two new hospital systems
including HCA in Portsmouth, New Hampshire the Portsmouth Regional
Hospital in 1987 and a Catholic hospital, the Good Samaritan Hospital
in southern Illinois in 2014. In both projects I worked hand in hand
with hospital administrators, department heads and nursing directors. I
have also had the nurturing experience to practice at a very busy
tertiary care center, The Heart Hospital of New Mexico (2004-2007) in
Albuquerque, NM. All these experiences were ``can do'' experiences. So
all in all, one could say that I have been ``around the block ``a bit.
On my arrival at VA Manchester it did not take long to appreciate how
separated, disconnected and disempowered providers were here.
Physicians were completely disenfranchised regarding any input in
directing the medical center programs at the VA. There were no direct
educational seminars or grand rounds in which providers and physicians
could commiserate as well as discuss professional issues together.
Almost all provider communications are digital and rarely by phone or
face to face. This was disheartening and at the same time disappointing
for it was not a culture I was accustomed to in contrast to my previous
hospital practices where I typically had in person contact with other
physicians. It sadly remains an academically and socially sterile place
here today which I believe detracts from a challenging and stimulating
collegial work environment that it could be and in turn potentially
translate into quality Medicare care. If only our ORs were so sterile
and antiseptic.
The next jolting revelation was that the medical center was
essentially run by the administrative level nursing staff (rather than
physicians) who were ill equipped to manage a medical center. I have no
axe to grind against nurses in fact far from it having worked in my
career quite smoothly and collaboratively with nursing staff. But here
I readily became aware that the most if not all hospital services
including operating room, pharmacy and urgent care center were overseen
by the Head of Nursing, Carol Williams, RN. She fortunately retired in
August 2017 after pressure from whistle blowers and the Boston Globe
article. Most of the programmatic and fiscal decisions were run through
Ms. Williams and officiated by Danielle Ocker the hospital director who
was also dismissed in summer 2017. This was an outrageous revelation
that there was virtually no input from practicing physicians regarding
management at the VA. Between 2014-2016 the nuclear camera in radiology
was breaking down several times per month. This is a critical
diagnostic tool used for stress testing and needed assess patients for
coronary disease. It was in dire need of replacing. Chest pain work ups
and pre-op patients were being rescheduled and truly inconvenienced.
Administration also would not fund rental of a nuclear camera which
could have ameliorated the problem. This was and remains a culture of
``no it can't be done'' here. Despite administrative promises, we were
informed in January of this year that funding was not available for
design and construction for the CT/Nuclear camera as well. The COS,
James Schlosser, MD indicated that stress test patients would have to
be sent to Boston much less preferable to veterans or that they would
have to rely upon a very broken VA Choice program administered by an
even less timely Health Net scheduling program for Non VA referral.
This was a very faulty program that was subsequently indicted for gross
delays in scheduling specialty testing and thankfully scrapped. This
type of delay in care is tantamount to the optic of a cardiac patient
with chest pain sitting in traffic on route 95 considering popping
nitroglycerin and waiting for the traffic to clear en route to their
stress tests to a referral center.
My former cardiology colleague, Dr Lombardi announced his plans for
enter private practice in December 2016 with his subsequent departure
in late January 2017. When discussing the hiring of a full-time
Cardiologist to replace him with Danielle Ocker and Carol Williams, Ms.
Williams made the disturbing comment that she was distracted by the
need to hire 10 housekeepers for the hospital. She had to ``balance
their fiscal resources''. It was frankly outrageous that Ms. Ocker and
Williams had hired at least 70 non-clinical staff that the hospital
could neither afford nor need. We needed providers not more educators
and non-clinical staff. I might add that prior to Dr. Lombardi's
departure, SAC Cardiology had 3 providers. Our program was touting a
90% access rating but unfortunately this declined to 37% in the second
quarter due to the staffing shortfall in Cardiology. We will be seeing
an additional 0.3 FTE Cardiologist added this month.
This compilation of events and others which will be presented today
brought myself, Dr. William ``Ed''Kois and Dr. Stuart Levenson together
and along with eight other whistle blowers to expose the gross
mismanagement that has occurred during our tenure here at the
Manchester VA and and bring us to propose potential solutions to
provide better access to convenient high quality medical care for our
veterans.
The Manchester VA and members of the Task Force have their work cut
out for them. Many choices, platforms and solutions will be considered.
The first choice which may be least desirable to providers and for most
veterans which is complete privatization as some legislators have
hinted. The second is a hybrid public-private partnership plan culling
out some least accessible medical and surgical specialty services and
shunting them to the private sector. I do think that services such as
Cardiology, Pulmonary, Oncology and mental health services could be
bolstered at the Medical Center. For example the development of a
hospital based comprehensive heart failure case management program
would save millions of federal dollars and reduce CHF readmission
rates. The third option and most challenging is resurrecting and
rebuilding a ``full service'' inpatient facility service here. This
would be a daunting task indeed. I do believe that whatever direction
or directions this ship will sail toward it most certainly requires
experienced, talented and energetic administrators who are not just
skilled navigators of stormy seas but also change masters who can
improve a dysfunctional institutional culture we have here today. Thank
you for your attention.
Stewart I Levenson MD FACR
Mr. Chairman and Members of the Committee,
Thank you for allowing me to submit this statement regarding my
efforts for reform at the Manchester VA Medical Center.
As a physician I have been employed until recently at the
Manchester VA Medical Center. I was initially hired to provide both
primary care and rheumatology services. Within the last several years
in Manchester I became the department chairman and then the New England
Network Director of the Medicine Service Line. During my tenure I have
been given assignments as the chief of primary care and the chief of
urgent care. I have also been assigned to another medical center as the
assistant to the director. As you are all aware the Manchester VA has
been featured in a Boston Globe article exposing deficiencies in care.
Despite efforts on the part of myself and the other so called
whistleblowers no corrective action had been taken until this article
was published.
These efforts began individually by concerned physicians who worked
to improve care on their own through official channels. Only when
frustration was voiced to each other in informal associations, was it
learned that problems were endemic and were a common experience. At
that point the individual physicians came together to try to address
problems as a group. Regular meetings were held and discussions were
undertaken to try to sway the leadership. Not only was this effort
unsuccessful but retaliation was meted out by the leadership. As the
core of the group that became known as the whistleblowers grew we would
meet with the medical center director and then by early 2016 meet with
members of Congress. I myself became frustrated with the pace of action
so I contacted the Boston Globe Spotlight Team. The Globe staff felt
the issue compelling and conducted in depth interviews. This led to the
publication which brought the current scrutiny to the issues of
patient's receiving substandard care.
Each member of the whistleblowers is witness to individual issues
but also shares the common experiences which make up the shoddy care
provided our veterans. As a leader I myself became the recipient of
concerns brought to me by my subordinates.
The first major issue that became a concern for our group of
physicians was noted in cardiology. This issue had to do with care of a
stroke patient that eventually led to the $21M judgment against the
medical center. It also led to the unfair smearing of physicians who
were directly involved in trying to improve care at the medical center.
In approx. 2003 the medicine division hired a full time
cardiologist for the first time. Dr. Dan Lombardi wasted no time in
bringing to my attention the shortcomings of the echo tech who
performed cardiac echos. It seems that this tech never had any formal
industry recognized training. She had only received on the job training
through the VA. She had no certifications and had no interest in
gaining any expertise. Dr. Lombardi repeatedly brought his concerns to
me and I forwarded them to the tech's supervisor, who was the recently
removed nurse executive, Carol Williams. Ms. Williams was not only
unsympathetic but showed no interest in correcting the problem even
when the Boston VA Medical Center commented that the quality of the
echos was so bad that no cardiologist should validate the studies.
Having our complaints fall upon deaf ears our cardiology division
functioned as best it could. This culminated with the echo of a patient
with a question of a cardiac derived embolic stroke being referred for
a trans esophageal echo. The tech was unable to perform the study,
blaming the problem on a faulty probe. It was later learned that the
tech did not know how to turn on the probe.
The acceptance of incompetence is a common theme. When Dr. Kois
took over as the staff physician in the spinal cord clinic he expressed
similar concerns with regard to spinal cord patients. Concerns were
brought to upper leadership and completely ignored. If a member of
upper leadership tried to intervene they too would face retaliation.
Dr. Anderw J. Breuder, the long time chief of staff, tried to assist in
dealing with issues, and was removed from his position on a thin
pretext. Like myself he tired of fighting and retired from the VA.
The committee will receive many statements dealing with individual
issues. I will instead deal with the common threads. One obvious issue
is that the VA cannot police itself. Investigations done internally
become nothing more than farce, and usually end with retaliation
against those who instigated the complaint process. Such was the case
with Dr. Brueder. This also occurred with myself. The office of
Inspector General conducts incompetent investigations geared at
scapegoating and then forwards its results to Administrative Review
Boards. These boards then single out a scapegoat and retaliation is
undertaken. This happened to myself several years ago. It is currently
happening to Gary Von George the business office chief who questioned
the director's management of the Choice program. Other examples
continue to arise.
Leadership covers for each other and when caught is allowed to
transfer to another position in the network. Tammy Krueger (formerly
Follensbee), refused to deal with problems that led to the huge
malpractice judgment. She also stood by while other patients were
endangered in Urgent Care. As acting chief of urgent care I brought
problems to her almost daily. As retaliation for doing this I was
passed over for the position of chief of staff. Despite my track record
of success, I was not even given a second interview. When the issues in
urgent care came to light Ms. Krueger was allowed to transfer to a
position at the VISN headquarters. In a move that would be comic if not
so tragic, she is now being named to the task force to study problems
at Manchester.
Other incompetent leaders seem to reappear as well. Even Dr. James
Schlosser, the incompetent chief of staff who was recently removed is
being considered for the Care in the Community Coordinator. This
position is actually constructed to deal with problems that Dr.
Schlosser himself created. I personally can think of no greater irony.
Incompetent failed leaders being repeatedly placed in positions of
authority occurs repeatedly. Danielle Ocker the removed medical center
director also fits this mold. Her own issues led to removal at White
River VA and could have predicted her poor performance at the
Manchester VA. Reviewing the education alone of these leaders should
have been a red flag to begin with. It is my understanding that Ms
Kreuger and Ms Ocker have only on line rudimentary degrees. In Ms.
Ocker's case it is from a for profit institution.
Much of the blame for the problems in Manchester I place with Dr.
Michael Mayo-Smith the VISN 1 Network director. There is simply no way
that Dr. Mayo-Smith could have remained unaware of the problems at
Manchester or the other medical centers for any length of time. His
insular style of leadership can only be compared to Nero fiddling while
Rome burned. While much of his discussions about the problems at
Manchester occurred behind closed doors, he would comment on the
problems at various times such as the monthly video conference referred
to as ``Super Tuesday.'' I myself have informed him of problems only to
be told that they are to be handled by local leadership. As of late I
have been in frequent contact with Dr. Mayo-Smith and have tried to
find common ground going forward. I truly believe we both want the same
outcomes for our veterans. Yet when confronting him about recent issues
he still falls back on the reply that the local leadership should
handle this. Is it any wonder why these issues that endanger veterans
continue unabated?
One of the greatest areas of incompetence is in the area of
wasteful spending. This has had a huge impact upon patient care.
Through hiring of non clinical personnel and other excessive spending
Danielle Ocker placed the medical center in a deep financial deficit.
Without regard for patient safety and with the full knowledge and
cooperation of Dr. Mayo-Smith and Dr. Schlosser clinical programs were
curtailed. The money for care in the community hospitalizations was
most affected. Patients were no longer being admitted to a local
community hospital but only to VA facilities. This led to decreased
satisfaction and mistrust. It seemed that if a patient had to be
admitted to a local hospital it came directly at the expense of an on
site clinical program. A single hospitalization could cost the same as
an entire clinical employee FTEE. Schlosser Ocker and Mayo-Smith stood
by while programs were being decimated.
Even as this committee meets, millions of dollars are being wasted
at Manchester. When the water pipe burst it was estimated that it would
cost $10M to bring the building back on line. This building is well
past its useful life and is now being evaluated for replacement. If it
is decided that the building needs to be replaced the money spent
repairing it is a total loss.
This speaks to a larger issue. Manchester is not the only VA that
is exposed in the news. In fact it is so commonplace to see a story
describing a VA as being terrible, that these stories fail to make the
national press. In the VA system there is a culture of incompetence.
Meeting measurements at the expense of providing good care, following
rules while ignoring common sense and experience, are deeply ingrained
in the corporate culture. The VA is a failed system that fails to keep
its promise to veterans. Leadership is incompetent, money is wasted and
good hardworking employees are harassed and retaliated against for
trying to provide excellent care. Unless the VA changes on a
fundamental level, the only solution will be to shutter it and move to
a system of privatization. This in my opinion would be a mistake. The
VA is the largest integrated health care system in the United States.
It could be a model for providing efficient healthcare to all US
citizens, instead it has become a national tragedy.
Ritamarie Moscola, MD, MPH, CMD, CPE
Mr. Chairman and Members of the Committee,
On or around June 30, 2016, we placed veterans requesting home
maker home health services and service in adult day health care centers
on the Electronic Wait List (EWL). This was at the direction of the
Medical Center Director, Danielle Ocker and the Chief of Staff, James
Schlosser. Over the course of several months we attended weekly
meetings during which the EWL for Geriatric and Extended Care (GEC)
services was discussed. Senior Leadership was present. We requested
guidance on removing veterans from the EWL. We did not receive approval
to move forward.
In February, the Director responded that we needed more
investigation into the process. VISN leadership was aware because the
veterans triggered on the consults pending for >90 days.
On July 11, James Schlosser commented at monthly meeting with VISN
that Manchester was the only facility with EWL for GEC services.
On July 17, I received an email stream stating that Manchester was
not the only facility with GEC-EWL.
On July 17, I received an email stream documenting that Manchester
was not the only facility with GEC-EWL. I was asked how I was going to
address this. I called a meeting of the staff working on providing
these services. I told them that we would review veterans with new and
old consults for eligibility. We would refer all those meeting
eligibility requirements to the appropriate home health agency or adult
day health care facility. Later in July, Corey Wilson, the Acting Chief
of Business Office, contacted the GEC nurse and gave her assignments
regarding the EWL and consults. No one spoke with me about changes in
job descriptions and duties even though I am the Service Line Manager.
On 8/28, at meeting with GEC staff, the Acting Chief of Staff of
Business Office, I learned that the review of consults for home maker
home health services was being removed from GEC and transferred to him.
He asked me why I created the EWL for GEC services. I responded that I
was told to do this by Senior Leadership due to the budget. He
commented that there was always money in the system for GEC services.
Electronic Wait List Numbers:
Veteran Directed: 62
Adult Day Health Care: 34 with 5 veterans on the EWL for
over one year.
Home Maker Home Health Aide: 138
Mark Sughrue, ACNP
Thank you for allowing me to address some of my observations. I was
unable to make the hearing as I have Veterans scheduled to see me in
clinic and I always try to defer to my Veterans and try not to
reschedule them unless absolutely necessary.
1.The nuclear camera has been due for replacement for over three
years as it has been obsolete and parts have only been available by
retrieving from old machines. The camera has failed on occasions
causing patients to have to repeat tests getting dosed by radiation
more than one time to complete testing. The National Acquisition Center
has purchased a new camera to be installed apparently pending the local
Medical Center paying for the installation. The Manchester VAMC
initially failed to account for the installation costs delaying the
install more than 3 years ago then delayed in obtaining the designs for
the construction to install the camera. The camera install was delayed
again until the next Fiscal year 2017 for install with the excuse of
``no money left to cover the install''. Then the administration decided
to delay installation of the camera as the nuclear technician decided
to retire despite the assurance that construction would begin early
2017and be completed by August of 2017. The timeframe for installation
of the new camera is still not known but not until at least 2018
roughly 4 years after the process started.
2.The administration at the VAMC failed to plan for the anticipated
downtime that was going to be required during the installation of the
camera despite multiple requests from Cardiology and Radiology to
consider the downtime. The response in early 2016 was ``we will utilize
Veterans Choice to bridge the construction time''. When cardiology and
radiology both stated the fact that VA Choice would delay care and
potentially cause patients to fail testing the administration continued
to plan for VA Choice to bridge the install time. When cardiology and
radiology repeatedly pointed out to the administration that the cost of
renting a camera to bridge the 6 month construction gap time would only
cost $26,000 approx. for 6 months and allow for quicker safer testing
at the Manchester VAMC the administration still decided to pursue VA
Choice as the preferred option. For example of ineffective VA Choice
testing when the cardiology echo technician went out on emergency leave
for medical injury VA Choice was utilized instead of hiring a temporary
echo tech and keep cardiology echo at the Manchester VAMC. For 3 months
cardiac echo tests were referred to VA Choice to be completed. After 3
months almost 300 echo tests were returned to the Manchester VAMC as
not completed by VA Choice, both delaying care to Veterans at great
risk and increasing cost as now many man hours had to be dedicated to
rescheduling and triaging the echoes for priority. The typical cost of
a nuclear stress test is approximately $4000. The administration of the
Manchester VA decided instead of spending $26,000 for 6 months of
nuclear stress test (roughly 150 stress tests) that cost shifting to
failed VA Choice program was more beneficial. It is clear that the
benefit was not for the Veteran but rather for the bottom line of the
administration.
3.The administration decided not to act to maintain the nuclear
department despite persistent requests from Cardiology and Radiology.
There was a full time and a part time nuclear technician until Fall
2016. The part time nuclear technician wanted to become a full time
nuclear technician but the administration had declined to make her full
time (despite being aware of the impending retirement of the full time
nuclear technician). That nuclear technician was offered a full time
position in Massachusetts outside of the VA and despite the pleading of
cardiology and radiology the administration continued to decline to
hire her full time so she left fall of 2016. The sole Nuclear
Technician got her retirement day finalized for the end of January
2017(it had been known she was going to retire for 2 years). From fall
of 2016 through January 2017 the administration would not pursue any
plan to install the camera or replace the nuclear technician despite
now having a firm retirement date. The administration actually allowed
the nuclear camera to go unrepaired with a function called attenuation
correction because it was ``going to be replaced and they didn't want
to spend any further money on the camera''. Then 1 week prior to the
remaining nuclear technician's retirement there was an emergency
meeting held the week of January 14th 2017. Present was Chief of Staff
Dr Schlosser, Chief of Nursing Carol Williams, Associate Chief Nurse
Linda Pimenta, Chief of Radiology, Chief of Medical Specialty Dr
Levenson, Nursing Supervisor of Specialty and Acute Care Shauna
Dalleva, Dr Funk Cardiology, myself Mark Sughrue Nurse Practitioner
Cardiology, Lead Technician Radiology Doreen Mitchell, business office
representative, a union representative, and a patient safety
representative were present. At this meeting a plan for nuclear testing
including nuclear stress tests, nuclear imaging for other departments
were considered. Cardiology, Chief of Medicine, nursing supervisor of
Specialty and Acute Care, radiology, business office and patient safety
all expressed the concerns with choosing to send nuclear testing to VA
Choice (especially in the setting of known failures with doing exactly
that with echoes which was a failure as noted above and no change had
occurred to improve VA Choice at that time). Manchester averaged 11
days to completion of stress tests (which included weekends and
holidays when testing not completed and patient's desires to schedule
into the future for planning etc). It was known that VA Choice could
routinely take up to 7 days to even make first contact with patients
followed by 30 days to actually schedule the test and up to 60 days to
return the results to the VA. I suggested that the nuclear department
not be closed due to above factors and the known delay in care as well
as some cases of VA Choice not even completing testing as a patient
safety, public health and increased cost to overall VA operations. Dr
Funk also stated his opposition to closing the nuclear department and
sending patients to VA Choice. Business office expressed similar
concerns and felt the volume of test would overwhelm current staffing
in business office who were unable to follow VA Choice effectively
already. The administration stated that since the nuclear technician
was leaving and a cardiologist was also leaving that the ``utilization
of VA choice was the best course''. When cardiology requested they hire
a new technician and cardiologist so that the nuclear department could
be kept the leadership including Carol Williams and Dr Schlosser both
stated that the Manchester VAMC didn't have the money to hire anyone.
Carol Williams stated that Manchester VAMC ``can't recruit a new
cardiologist as we have to hire housekeepers, we are down 10
housekeepers''. Linda Pimenta expressed that hard decisions had to be
made but there was no money to make any other choices other than VA
Choice. All of the above safety and delay concerns were felt to not be
enough to choose not using VA Choice according to leadership that was
present including Chief of Staff, Chief of Nursing, and Associate Chief
of nursing. The plan became no technician would be hired until the new
camera was installed which was then planned for fiscal year 2018 and
that VA Choice would be used to complete nuclear testing for at least
the next 10 months.
4.The typical cost of nuclear stress testing is approx $4000. The
Manchester VAMC averaged 350 nuclear stress tests per year totaling
$1.4 million in cost shifted to VA Choice budget from the Manchester
VAMC budget. The cost to complete at Manchester VAMC would include
partial salary for Cardiologist and Cardiology Nurse Practitioner(who
also completes other patient visits), EKG technician (who also has
other duties), Nuclear technician (also completes nuclear testing for
other tests), cost of the nuclear material, camera cost and other
various facilities cost which definitely costs less than $4000 per
test.The utilization of VA Choice enabled the Manchester VA
administration to cost shift the testing to the VA Choice budget
therefore ``saving the Manchester VA money'' as they say it. There was
no consideration from the administration regarding the proven concerns
and prior failures with utilizing VA Choice for time sensitive life
altering tests.
5.After the transition to utilization of VA Choice for nuclear
stress testing started in January of 2017 and through July 2017
multiple tests had not be scheduled or completed in some cases greater
than 3 months delay for symptomatic patients. Multiple patient safety
reports were been submitted with no action taken from the
administration to change plan or change plan to hire a nuclear
technician despite the old camera which at least was still partially
functioning was still present, no movement in actually hiring a
cardiologist (looking was approved but not hiring). The camera install
was apparently submitted improperly therefore it was not clear if it
will even be installed at this point and not any sooner than 2018 at
the earliest despite more than 3 years of knowing this equipment needed
substantial planning and redesign of the radiology department to
install. Manchester VAMC continued to refer patients to VA Choice
despite continued lack of scheduling and completion of the tests as of
mid May 2017.
6.After the Boston Globe article was released many changes in
action from the new administration to correct the errors of the prior
administration proceeded. The new acting director ordered the nuclear
camera restarted (cost to decommission and then the cost to
recommission likely more that the yearly salary of the nuclear
technician). Unfortunately, since no recruitment for a new nuclear
technician was started the nuclear stress department has yet to open
but the nuclear camera is being used for less complex non cardiac
testing.
7.A part time cardiologist was hired to increase availability of
cardiology resources, but this is still less than the number of
cardiologist available prior to the old administration effectively
dismantled the cardiology service line to save money.
Observations:
The connecting theme of most of the above decision points that the
Manchester VAMC administration made was completely driven by increasing
bureaucracy, cost shifting and was not driven by improving care for the
Veterans. The thought was never how can we make the Manchester VAMC a
destination for care. It was only about how do we cover the bottom line
because the Manchester VAMC budget and planning were lacking. Decisions
were made to hire multiple middle management but not new clinical staff
to actually see the Veterans and provide care despite the clinical
staff functioning at greater than capacity in nearly all departments.
An example is the creation of at least 2 new executive nursing
positions in the nursing hierarchy effectively creating more managers
to oversee less clinical staff because there ``wasn't enough money in
the budget to hire clinicians''. At no point along the multiple
decision points did the administration consider the input from the
content experts and front line personnel to make decisions for the
Veterans. The decisions were made in the dark and then dropped on the
clinical staff with only token ``listening sessions'' where input was
clearly not exploited.
What have I seen since the new acting director and the visit from
VA Secretary Shulkin came to the medical center. Some changes have been
positive such as more involvement of medical providers in decision
making for the medical center. It seems that the cardiology service
line is at least partially being rebuilt though still below prior
provider levels.
Unfortunately, I have also experienced ``more of the same/the VA
way'' still occurring. Officials removed from one job and placed in
other positions of power despite the many decisions made that knowingly
negatively affected Veterans. The hierarchy that enabled the poor and
unsafe care of our Veterans are still in place and continue to make
decisions without involvement of content experts and clinical staff. An
example which may seem small but can truly negatively affect patient
care. Electrocardiogram (EKG) electrodes were changed after being
approved by middle management, but no input was sought from cardiology
or clinical engineering (responsible for all medical devices throughout
the medical center) regarding the change. The result has been increased
artifact on EKGs especially during stress testing as the stickers don't
stick well on someone who is moving and sweaty. This could have been
avoided with less middle management making decisions without the
support and input of the clinical providers or at least content
experts.
I truly hope that the positive changes will be sustained but
concerns remain given the persistent atmosphere of entitlement from
certain staff and decisions made not because it is best for the Veteran
but for other reasons.
The VA should solely be motivated to be the destination of care for
our Veterans. I have seen some of that culture in the VA but it is not
pervasive and was not present in the prior administration and remains
in Manchester in some of the previously established hierarchy.
Gary Von George
My name is Gary Von George, and I am the Business Office Manager at
the Manchester VA Medical Center. I have been an employee with the
Department of Veterans Affairs for 33 years. I have held positions of
progressive responsibility throughout my career serving Veterans as I
have worked at three different VA Medical Centers within VISN 1 and at
our VISN 1 network office. Prior to July 26, 2017 I had not received
any adverse actions nor had I been counseled for any performance or
misconduct issues. On July 27, 2017 I received a letter from my
supervisor, Kevin Forrest, Associate Medical Center Director that
informed me that I was being detailed to the office of Mental Health as
an Administrative Officer, pending an investigation. This letter was
signed by Alfred Montoya, Acting Medical Center Director. This letter
is the result of recent communications that I have had with senior
leadership and possibly other investigative teams that I met with and
provided information to.
As the Business Office Manager for the Manchester VAMC, my duties
included oversight of the Community Care office. The Community Care
office is responsible for processing care that is referred to civilian
providers, when it cannot be delivered through VA processes. The
Veterans Choice Program, as it relates to New Hampshire Veterans, is
encumbered under the Community Care office. The Community Care office
at the Manchester VAMC has been understaffed throughout this Fiscal
Year. On June 30, 2016 the community care section lost 40% of the
community care case management staff as two of the nurse practitioners
took other positions within the VAMC. On October 1, 2016, the Chief,
Community Care became vacant as this person accepted another position
within the VISN. I immediately did the expected resource request, and
then the shell game of approving staff at the Quadrad level began. I
repeatedly asked for these positions to be filled through both written
and verbal communications to my supervisor and through written verbal
communications at various meetings.
On June 7, 2017 I sent an email to Kevin Forrest, Associate
Director and James Schlosser, Manchester VAMC Chief of Staff regarding
processes, budget concerns and possible misuse of the of Dental care as
it pertains to the non-VA Care dental process. I had identified several
instances of high dollar referrals for care that did not meet the
guidelines spelled out in the Community Care Dental Desk Top guide, to
include mismanagement of referrals over $1,000 which is a violation of
38 U.S.C. 1712. In addition, at a leadership meeting on June 8, 2017, I
further clarified verbally to leadership that I had identified what
seemed to be a large amount of dental care that was being referred to
one particular dental provider and that this care was not meeting the
consult review process of having a second level VA Dental opinion. On
July 5, 2017 the Manchester VAMC Privacy Officer sent me a Freedom Of
Information Act (FOIA) request that was received from the Boston Globe
on June 12, 2017. In this request, the Boston Globe is asking for
payments made to civilian dentists for a specific timeframe.
On July 21, 2017, Carol Williams, Nurse Executive sent out a
communication to all clinical staff that effective Monday, July 24,
2017 the Community Care section would be stood up as a new unit
separate from the Business Office and that it would be led by the
Social Work Chief. This was the first communication that I received
notifying me that this would be taking place and I immediately sent an
email to Kevin Forrest questioning why I was not kept in the loop as
the Service Line Manager. On July 22, 2017 at approximately 4:30 PM,
Kevin Forrest and I had a telephone conversation regarding this
process. During this conversation, I informed Mr. Forrest that I have
personally witnessed Carol Williams ``bully'' her way around to get
what she wanted. I told Mr. Forrest that VACO Office of Community Care
was recommending a physician be placed in charge of this new office and
that ``with all that has been occurring here at the facility,
Manchester does not have the juice to go against what VACO is
recommending.'' This comment further proved to be true when VA
Undersecretary for Health, Dr Poonam Alaigh came to Manchester and
announced at a town hall meeting that the Community Care office would
be led by a physician.
On July 19th, I was told by leadership that the OMI wanted to
interview me. I presented to this interview and was asked about
Veterans Choice questions. As I was not sure what they were going to
ask me, and as such I was not fully prepared. It is important to note,
that when I was interviewed by OMI in January 2017, I was informed by
the former Quality Manager what the topic was. On July 26, I again met
with OMI and this meeting was set up at my request as I felt that I had
not been able to give the team a complete picture of Veterans Choice,
lack of support from the VISN 1 BIM and other concerns. During this
meeting, I clarified with OMI a request for information that I had
received from our leadership. I then disclosed to leadership that I had
net with OMI a second time and had clarification that I sought.
My case is a classic example of how this agency treats employees
that try to bring issues to light and they suspect of being a
whistleblower. Leadership removed me from my position and proceeded to
limit my access and knowledge. I have been blocked from program
folders, have had system access removed and have been removed from
pertinent mail groups that will hinder me from ever returning to my
position. The ``investigation'' against me is now entering its eighth
week and I have yet to be contacted by an investigator or be allowed to
defend myself against the charges. As I had built a reputation of trust
and respect amongst my peers here at the Manchester VAMC, the agency
has sent a clear cut message to all other employees at the Manchester
VA of what will happen to you if you challenge their norm or talk to
institutions outside of their control. I had not spoken to the Boston
Globe regarding the dental issue or any of my Veterans Choice concerns,
as I instead preferred to work within the VA system, a healthcare
system that I know and believe in, as it serves our nation's highest
heroes.
Edward Chibaro, MD
John McNemar, DNAP, CRNA
Stephen Dubois, CRNA
The surgical and anesthesia staffs represented are comprised of
three providers. One surgeon and two are anesthesia providers. All
three providers documented multiple areas of severe deficiency and
offered suggestions and recommendations.
There has been lengthy discussion with regard to absent and
outdated surgical and anesthesia equipment and instrumentation.
Instruments have been repeatedly contaminated and flies were noted in
operating room number two. The Chief of Surgery step-down occurred as a
result of ineffective leadership, lack of productivity, unsettling day-
to-day conflict and relentless opposition to develop a prestigious
surgical program with Veterans as the top priority. The current acting
one-day-a-week acting Chief of Surgery defers to the OR nurse manager
the remainder of the week. In his absence she executes Chief of Surgery
duties. Medical staff members have noted the acting chief of staff
expresses no interest in Manchester and habitually dismisses concepts
and ideas brought forth by permanent Manchester staff. The
administrative support staff for surgery is located on different floors
and is of very limited assistance to operating room ventures.
A robust culture of disrespect prevails in the OR and most of the
medical center. Antagonistic interpersonal work relationships are the
daily norm in the operating room. Nurses have refused to execute
physician and/or provider orders, only to receive full support from
nursing leadership. A concerning number of staff sign-on for employment
then quickly resign from the Manchester VA.
The nurse manager bullies nursing staff, housekeepers and others.
She has browbeaten and intimidated staff in the presence of nursing
leadership, chief of staff and other administrators, and has not been
admonished whatsoever. She has reprimanded staff in view of patients.
She has lied, exhibited inferior sterile technique, encouraged the use
of contaminated instruments and violated multiple Joint Commission
guidelines for unprofessional behaviors. Nursing staff have complained
about not receiving lunch breaks, often while the nurse manager and
assistant nurse manager are sitting at their desks, in their offices.
She inaccurately educated staff with respect to the World Health
Organizations mandated protocol for the ``time-out'' procedure and
encouraged staff to refrain from calling for emergency assistance in
the event of a code blue. She has requested that providers fill in for
OR nursing lunch breaks, an extraordinarily unorthodox request. She was
noted to have not properly logged critical OR incidents, such as
humidity control and contamination problems. She was unable to track
cases cancelled due to contaminated equipment. Her direction of an OR
remodel yielded absent emergency call intercoms or code blue buttons
standardly found in operating rooms. Manchester VA administration, the
Office of Medical Investigation and the Office of Whistleblower and
Accountability have received numerous letters of complaint written by
staff members from many disciplines, including physicians and other
providers. Her supervisor is incapable of resolving everyday clinical
issues and is completely unknowledgeable with regards to OR routines,
primarily because her background is in primary care. Frivolous,
expensive and unnecessary office renovations were approved and directed
by the nurse manager. These renovations superseded recurrent pleas for
essential staff, essential equipment and essential instruments required
for patient care and patient safety. More extensive and serious
concerns have been documented and shared with VA administration and
multiple internal VA investigative agencies.
The culture in the operating room at the Manchester VA parallels
the noxious culture throughout the remainder of the facility. There is
a forceful refusal to collaborate on vital topics and a customary
atmosphere of autocratic execution and rogue decision making. Expensive
and critical surgical and anesthesia supplies and equipment were
independently ordered by nursing staff, without approval, collaboration
or any stakeholder participation. This autocratic culture remains
active today and is everyday business in the Manchester OR. Focus
groups, task forces and team methodologies are all baseline concepts in
any operating room, yet do not exist in the Manchester OR. Vital
support staff has been repetitively requested, agreed to and confirmed,
only to later be cancelled and denied. Communications are nearly non-
existent. Most personnel do not respond via phone, email or otherwise.
Providers are essentially on their own, often left to flail and
fail. They receive little to no support by means of staff,
administration or other.
ENT surgeon Dr. James Snyder, a US Navy Captain and highly renowned
surgeon in the community, was personally called and recruited to the
Manchester VA last year by then Undersecretary Dr. David Shulken. In
his time in Manchester, Dr. Snyder struggled to get instruments and
assistance. He received no help from OR staff, leadership or
administration. After being pushed to his limits when offered a
miniscule workspace after the recent flood, he submitted a resignation.
The administration neither appeared concerned, nor tried to
troubleshoot the resignation and convince him to stay. Meanwhile, many
staff members were and are in spacious offices that could have
temporarily served Dr. Snyder to complete his work. Leadership is
indifferent to the loss of valued staff and administration appears
expressionless, despite a revolving door of employees.
Several years ago anesthesia providers had no method for drug
administration. This virtually did not exist. In high-risk fashion,
medications were removed outside of the OR and carried in for each
patient, every case. Emergency drugs were not present and pharmacy
personnel provided enormous levels of opposition and defiance when
workable resolutions were suggested. Patients about to receive
anesthesia get little time with anesthesia providers as providers are
required to restock anesthesia supplies and clean equipment between
each and every case. This highly irregular practice is necessitated as
anesthesia has no support staff. After submitting countless literature
sources in support of hiring this staff member to administration,
anesthesia staff was repeatedly promised this position would be hired,
only to be repeatedly denied. The OR pharmacist had little to no
knowledge regarding anesthesia medications and ASHP (American Society
of Health-System Pharmacists) and ISMP (Institute for Safe Medication
Practices) protocols and guidelines. Pharmacy personnel attempted to
require anesthesia providers to pick up and drop off anesthesia drugs,
a practice that would be considered highly irregular. Pharmacy
technicians restock medications in all operating rooms, but at the
Manchester VA they are not permitted in the OR by order of the nurse
manager. Pharmacy involvement is minimal as related to anesthesia,
which is also highly irregular. Pharmacy personnel ``lost'' a large
number of Propofol vials, the liquid anesthetic that killed Michael
Jackson. Pharmacy personnel then accused anesthesia staff of diverting
the drug, an accusation that was later rescinded in a letter of apology
written by the Chief of Staff. To date, there has been no follow up
with anesthesia as to the status of those missing vials. Pharmacy
personnel attempted to have a standardized drug return bin removed from
the exterior of the not-yet-purchased anesthesia dispensing cabinets
that will be ordered. This is a violation of ISMP protocols (Institute
for Safe Medication Administration) and an action that will make duties
easier for pharmacy personnel, while increasing risk of incorrect
medication administration to patients and increasing liability for
providers and the Medical Center. This hazardous notion has more
recently been supported by the interim Chief of Surgery from the White
River Junction VA Medical Center, who is a surgeon and appears
unacquainted with the potential safety implications of this deviance
from recommended guidelines.
Providers are habitually excluded from involvement with decision
making that affects their specific practice, while other uninformed
staff members are incapable of completing their own duties because they
are diligently working to execute duties that are not their own. This
peculiar practice is unconventional, yet customary in Manchester.
Providers must be integrated into their own areas of expertise and
empowered to regulate their professional practice. They must also be
consistently and sincerely acknowledged when conveying undisputable
practice concerns. Investments into essential staff and essential
equipment must be supported to provide proper care, and the use of
standards of practice and recommended guidelines must be compulsory and
established with an evidence-based framework. There is an imperative
need to educate all Manchester VA personnel with regards to the zero
tolerance policy for disruptive behavior as recommended by the Joint
Commission. Rudeness, disrespect and intolerance must be replaced with
optimism, kindness and basic mutual civility. This policy has to be
strictly adhered to locally and all employees held accountable for
their approach as the Medical Center endeavors the paradigm shift from
a culture of disrespect to a culture of respect.
Questions For The Record
LETTER TO HONORABLE DAVID SHULKIN
The Honorable David J, Shulkin Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Shulkin,
Please provide written responses to the attached questions for the
record regarding the Subcommittee on Oversight and Investigations field
hearing entitled, ``An Assessment of Leadership Failures at the
Manchester'' that took place on September 18, 2017. In responding to
these questions for the record, please answer each question in order
using single-spaced formatting. Please also restate each question in
its entirety before each answer. Please provide your responses by the
close of business on Friday, November 10, 2017. Answers to these
questions for the record should be sent to Mrs. Tamara Bonzanto at
[email protected] and Ms. Grace Rodden at
[email protected], copying Ms. Alissa Strawcutter at
[email protected]. Ifyou have any questions, please do
not hesitate to have your staff contact Mr. Jon Hodnette, Majority
Staff Director, Subcommittee on Oversight and Investigations, at 202-
225-3569.
Sincerely,
Nc::J---
Chairman
Subcommittee on Oversight and Investigations CJB/tb
Cc: Ann McLane Kuster, Ranking Member Attachments
``An Assessment of Leadership Failures at the Manchester''
Questions from Chairman Jack Bergman
1. During the hearing, Dr. Mayo-Smith testified that he knew about
some of the concerns raised by whistleblowers prior to the publication
of the Boston Globe report, and he found out about others after the
report was published. Dr. Kois stated that he and other whistleblowers
raised and tried to address the myelopathy cases with Dr. Mayo-Smith
for years, and the Veteran Integrated Service Network (VISN) did not
take appropriate action to respond. Please inform me when Dr. Mayo-
Smith was first made aware of the issues with the myelopathy cases, and
what actions he and the VISN took to address those issues. Please
include a timeline with the response.
2. What processes are in place at the VISN to ensure there is
proper oversight of community care offices at each facility?
3. Has VHA completed a review of the deficiencies at the VISN,
specifically within the business office? If yes, were there any
findings?
4. What are the VISN's plans to improve coordination of inpatient
mental health services within the network?
Questions from Ranking Member Ann McLane Kuster
1. What VHA and Manchester VAMC processes exist to remedy training
deficiencies in medical support staff?
2. What actions are supervisors and clinicians- required to
immediately take upon discovery of training deficiencies and to ensure
patient safety and quality of care in these instances?
3. What on-the-job training is provided for medical support staff?
4. What required actions do VISN Directors take when they receive
patient safety and quality of care -complaints?
5. When VISN Directors receive complaints fro1n VA employees, how
do they determine whetl1er a complaint should be addressed at the
medical facility level, the Network level, or at VA Central Office?
6. What actions are being taken at the facility level, Network
level, and at VA Central Office to address cultural and human resources
issues that have contributed to the current workplace environment at
the Manchester VAMC?
7. What actions has the Manchester VAMC and the VISN taken to
protect VA whistleblowers and notify VA employees of their rights to
provide information to the VA Office oflnspector General (JG), the
Office of Special Counsel (OSC), the Office of Accountability and
Whistleblower Protection (QAWP) and Congress?
8. What actions will the Manchester VAMCd the Network take to hold
supervisors who retaliate against VA employees accountable?
9. How will the Manchester VA incorporate physicians' input in
management of the medical center's programs?
10. What provider professional educational opportunities exist at
the Manchester VAMC?
11. Do forums exist for physicians and providers to raise and
address issues concerning clinical operations?
12. How are staffing priorities made at the facility and VISN
level?
13. Was the Manchester VA leadership incentivized to send veterans
to community providers for treatment via the Choice Program instead of
providing care at the Manchester VAMC as a cost-saving measure?
14. Are facility directors required to report provider vacancie's
and plan for new hires and attrition in the plan and budget for each
fiscal year?
15. How many providers would Manchester VAMC need to hire to fully
restore the cardiology service line?
16. What recruiting efforts have the Manchester VAMC taken to
identify a permanent director and hire a new Chief of Staff, and when
does the facility expect to have these positions filled at the
facility?
VA GFR RESPONSE
Questions for the Record
``An Assessment of Leadership Failures at the Manchester, N.H. VA
Medical Center''
Questions from Chairman Jack Bergman
Question 1. During the hearing, Dr. Mayo-Smith testified that he
knew about some of the concerns raised by whistleblowers prior to the
publication of the Boston Globe report, and he found out about others
after the report was published. Dr. Kois stated that he and other
whistleblowers raised and tried to address the myelopathy cases with
Dr. Mayo-Smith for years, and the Veteran Integrated Service Network
(VISN) did not take appropriate action to respond. Please inform me
when Dr. Mayo-Smith was first made aware of the issues with the
myelopathy cases, and what actions he and the VISN took to address
those issues. Please include a timeline with the response.
VA Response: Please see the attached document.
1.In order to document communications with the whistleblowers Dr.
Mayo-Smith asked OI&T to identify all emails from or to or mentioning
the whistleblowers from January 2014 through July 2017. As Network
Director all his emails are archived. In addition staff at the Network
Office reviewed the files of written correspondence, communication to
the ``Ask the Network Director'' option on the VISN website, the
presentations by service line leads during their annual briefing to the
Network Director and the minutes of the meetings of the Service Line
Leads. This is of interest as Dr. Stuart Levenson was serving as the
Medicine Service Line Lead for the Network and participated in these
meetings.
2.There was no written correspondence to the Network Director by
any of the whistleblowers during this period. There were no submissions
from any of the whistleblowers to the Network Director via the ``Ask
the Network Director'' button on the VISN website. There were no in-
person or telephone meetings requested or held with any of the
whistleblowers. No emails from Dr. Kois were identified by OIT in their
search of the files.
3.The review of Medicine, Surgery, and Rehabilitation Service Line
presentations in 2015, 2016, and 2017 did not reveal that the issues of
concern were raised at these meetings. As noted Dr. Levenson was the
Service Line Lead for Medicine. Dr. Chibaro also served as the Chief of
Surgery and was present at the Surgery meetings. Neither the Network
Director nor others present recall any of the issues of concern being
raised verbally. Similarly review of the minutes and inquiry of those
present established that the issues of concern were never raised during
the monthly Service Line Leads meetings with the Chief Medical Officer.
4.In 2015, Dr. Mayo-Smith had the opportunity to meet with Dr.
Kois. He had been mentioned by the leadership at Manchester as a new
hire who was skilled in managing chronic pain patients. Dr. Mayo-Smith
requested to meet him during a site visit and visited him in his clinic
as management of chronic pain was a priority for VISN 1. There was no
request from him to meet with the Network Director; the meeting was
initiated by Dr. Mayo-Smith. Dr. Mayo-Smith believes that at this
meeting Dr. Kois' concerns regarding myelopathy management was raised.
There were no concerns regarding this issue at other medical centers in
the Network. There was no VISN or National Policy directing management
of myelopathy. As this was a concern regarding care at Manchester, Dr.
Mayo-Smith recommended to him that he bring this up with the Chief of
Staff at Manchester. The VISN staff were available to assist if the
Chief of Staff felt it appropriate. Subsequently a request came from
Dr. Breuder, Manchester COS at the time, and Dr. Levenson, requesting
Dr. Fuller, VISN Chief Medical Officer at the time, to assist in
obtaining reviews 2-3 cases of patients who had undergone neurosurgery
in Boston. These concerns were not brought forward to Dr. Mayo-Smith,
but to Dr. Fuller. The cases were forwarded to Boston and underwent
both internal and external review, without significant findings. No
further concerns regarding myelopathy were brought forward to the
Network Director from Dr. Kois.
5.On September 12, 2017 Dr. Mayo-Smith emailed Dr. Kois and
inquired if he had copies of any correspondence, email or otherwise,
with Dr. Mayo-Smith related to the myelopathy issue. Dr. Kois did not
reply nor provide any evidence of communication on this issue.
6.Of interest is the letter from the whistleblowers' lawyer to
Senator Shaheen which identified their allegations. The following
bullets detail the timeline regarding the sharing of the contents of
the letter. They document that Dr. Mayo-Smith did not see the letter
and it's allegations until July 28, 2017.
Senator Shaheen notified Ms. Ocker of this letter on
September 12, 2016 but explicitly noted she was not identifying the
whistleblowers or their concerns. No copy of the letter was included.
January 2017 Office Special Counsel (OSC) requested
Office of Medical Inspector (OMI) to review specific concerns. OMI did
not receive a copy of the letter
March 2017 OMI visited Manchester to conduct their
investigation. In-brief and Out-brief were verbal. No copy of the
letter was shared, as OMI did not have it.
June 20, 2017 report from OMI was sent to OSC by VA COS.
It referenced concerns of ``a whistleblower''. No copy of the letter
was included, as VA did not have it.
July 28, 2017 a copy of the letter from the lawyer to OIG
was forwarded to VISN Office. Prior to July 28, 2017 neither Dr. Mayo-
Smith nor anyone else in VISN office had seen the contents of the
letter.
Question 2. What processes are in place at the VISN to ensure there
is proper oversight of community care offices at each facility?
VA Response: Veterans Integrated Service Network (VISN) 1 Business
Office Manager conducts weekly calls with the VA Medical Center (VAMC)
Business Office Managers to provide updates and problem shoot on
community care issues. There are weekly and monthly data dashboards
produced and distributed on community care. Community Care data are
also reviewed at the monthly performance video-conferences held by VISN
leadership with each medical center as well as at weekly Executive
Leadership Board meetings.
VISN 1 completed a Care in the Community Stand-Down in October
2017, led by the Deputy Network Director, during which each of the
other sites within the network was visited. The Stand-Down focused on
five key areas within Care in the Community and provided feedback
reports to all facilities for action if and where needed. In general,
medical support assistants were well-trained and familiar with
recommended procedures for referrals to choice. There were also
identified opportunities for improvement in the management of the
Veterans Choice list. Further, the VISN 1 Deputy Network Director, in
consultation with the VISN 1 Business Implementation Manager, has put
in place new components and controls as part of their facility site
visit program.
Question 3. Has VHA completed a review of the deficiencies at the
VISN, specifically within the business office? If yes, were there any
findings?
VA Response: Office of Medical Inspector and the Office of
Accountability and Whistleblower Protection have both completed a
second round of visits to the Manchester VAMC to complete an
investigation relative to Care in the Community within the Business
Office; the outcome of those investigations are pending.
Question 4. What are the VISN's plans to improve coordination of
inpatient mental health services within the network?
VA Response: In 2014, the VISN Mental Health Executive Council
embarked on a strategic initiative to improve inter-facility transfers
to ensure that Veterans requiring acute admission could be connected to
available resources as soon as possible. At the outset, Manchester
(which relies on external facilities for all admissions) and Boston
(with Brockton campus being the largest inpatient system in the VISN)
were identified as key partners to analyze and improve processes. In
the first year, a work group including mental health and urgent care
providers from both campuses met regularly to clarify communication
processes, including revised Standard Operating Procedures and a new
electronic inter-facility consult to simplify the referral process 24/
7. Manchester VAMC is actively transferring patients from Manchester
Urgent Care to Brockton on a 24/7/365 basis using an inter-facility
transfer template. These transfers happen on a regular basis and have
improved the flow of patients between those two facilities. VISN 1
Mental Health is beginning a work group to facilitate transfers between
Bedford and Brockton VA using a similar template to the one used by
Manchester VA and Brockton VA. These projects are both works in
progress. There are also plans (with a work group forming) to develop a
discharge template to aid in reconnecting patients to their home VAMC
to ensure continuity of care and follow up.
Questions from Ranking Member Ann McLane Kuster
Question 1. What VHA and Manchester VAMC processes exist to remedy
training deficiencies in medical support staff?
VA Response: Competence is determined through in-processing of new
employees and begins during the interview process. All employees must
attend new employee orientation. Once the employee is at their assigned
location, supervisors are responsible for ongoing competence and
identifying training needs in collaboration with employee. Many
training opportunities are available in VA's online Talent Management
System (TMS), in person training, in coordination with other VISN
medical centers, national training, webinars, live meetings,
conferences, etc.. In addition, a supervisor may assign a preceptor,
sponsor or mentor. All of the decisions for training begin with the
supervisor and employee identifying a training gap or need; the
supervisor may consult with the education officer for resources or
suggestions to meet training needs. All employees are encouraged to
develop a personal development plan and to self-identify their training
needs.
Question 2. What actions are supervisors and clinicians- required
to immediately take upon discovery of training deficiencies and to
ensure patient safety and quality of care in these instances?
VA Response: The immediate action or response is to stop the line
and take a time out to avoid injury and support safety. The Medical
Center has a link available on its webpage for reporting safety and
patient safety issues. Training and educational needs are evaluated on
all patient safety issues and Root Cause Analyses. Actions may include
just-in-time training, need to develop training and or competencies,
corrective counseling or discipline. The Medical Center`s Educational
Department, Quality Management Services, and Human Resources are
available to all supervisors to assist them in resolving any training
or educational deficiencies.
Question 3. What on-the-job training is provided for medical
support staff?
VA Response: VA offeres preceptor or sponsor assignment, Coach/
Mentor, new employee orientation, TMS trainings, scheduling training,
soft skills training (huge list of mandated training by groups of
employees), Leadership Enhancement and Development (LEAD), EEO
trainings, Excel computer classes onsite, simulations, skills training
(safe patient handling equipment, safety drills, mock codes). An annual
VISN-sponsored needs assessment is used to determine training/education
needs for all employees.
Question 4. What required actions do VISN Directors take when they
receive patient safety and quality of care complaints?
VA Response: Upon receipt of a complaint, the VISN will evaluate
the nature of the complaint often utilizing input from Chief Medical
Officer and other clinical subject matter experts within the network.
When indicated they will consult with the medical center to ensure
understanding of the complaint. Further action taken is then dependent
on the nature of the issue. Oftentimes, the matter is best managed at
the VAMC. In other cases, response at the VISN or National level may be
needed and are pursued through the appropriate channels. When these
involve complaints from patients regarding clinical care decisions
frequently a recommendation is made that the Veteran submit a clinical
appeal to the Network Director.
Question 5. When VISN Directors receive complaints from VA
employees, how do they determine whether a complaint should be
addressed at the medical facility level, the Network level, or at VA
Central Office?
VA Response: It would depend on the scope of the issue. They would
use their best judgement, consulting with Medical Center, VISN and
National subject Matter Experts as needed, to determine if the issue
can be solved locally or needs VISN or national resources.
Question 6. What actions are being taken at the facility level,
Network level, and at VA Central Office to address cultural and human
resources issues that have contributed to the current workplace
environment at the Manchester VAMC?
VA Response:
The Manchester Acting Chief of Staff (COS) proactively
reached out to the Veterans Health Adminsitration (VHA) National Center
for Organization Development (NCOD) for support in improving the work
environment in the clinical services at Manchester. NCOD consulted with
the Manchester Acting COS on assessing the current situation,
identifying potential challenges at the facility, and identifying
possible opportunities for NCOD support.
The Acting COS identified two specific services, Mental
Health and Surgery, for our initial focus and NCOD has agreed to
consult with the leadership of those two specific services and the
Acting COS. Consulting calls with each of those services is ongoing.
Manchester Acting Medical Center Director recently
reached out to NCOD regarding support for the facility. A call is
currently being scheduled to determine a plan for further NCOD support
facility-wide.
An organizational health survey was administered and part
of the support will be assisting in reviewing the data and action
planning based on identified issues.
The Acting Medical Center Director and the Network
Director have held monthly Town Hall sessions open to all employees. As
part of these Town Hall agendas, employees were briefed on The Way
Forward. This outlined a 5 step approach: 1. Rebuild Leadership, 2.
Restore Trust, 3. Improve Care, 4. Fix Choice and 5. Design the Future.
Additionally, the topics of treating each other respectfully,
eliminating waste and staffing of additional positions were discussed.
The Acting Medical Center Director is also working with NCOD to begin
tackling cultural issues that have been inherent for many years.
Additionally, the Acting Medical Center Director has
introduced a clinical advisory board consisting of all clinical staff
to have input into the decision making process at the Medical Center.
The VISN Director has made Employee Engagement a
Strategic Priority for the Network. VISN 1 has consulted with NCOD to
tackle the issues of culture within the Network. VISN 1 is also hiring
two organizational development specialists, one to be located at
Manchester VAMC. Service Line leaders have conducted multiple listening
sessions to ensure employees' voices are heard.
A VISN stand down is being led by the VISN Chief Medical Officer
and facility COS to determine if similar concerns expressed by
Manchester staff exist at other medical centers and to implement action
plans. Nationally NCOD has undertaken in depth analyses of Manchester
All Employee Survey results and shared with VHA leadership.
Question 7. What actions has the Manchester VAMC and the VISN taken
to protect VA whistleblowers and notify VA employees of their rights to
provide information to the VA Office of lnspector General (JG), the
Office of Special Counsel (OSC), the Office of Accountability and
Whistleblower Protection (QAWP) and Congress?
VA Response: VISN 1 has had over 1,400 Supervisor and Human
Resources staff complete training on whistleblower protection.
120 employees in VISN 1 have received ``Live Lync''
training from VA Chief Counsel artorneys on whistleblowewr protection.
All Medical Center Directors in VISN 1 have sent out
``All Employee'' emails providing links to whistleblower protection
information and websites to ensure visibility and promote
understanding.
All Executive Leadership Board members, including Medical
Center Directors and Service Line Leads attended a 4-hour, in person
Whistleblower training for Leaders led by Scott Foster, Human Resource
Consultant, Workforce Management.
Question 8. What actions will the Manchester VAMC and the Network
take to hold supervisors who retaliate against VA employees
accountable?
VA Response: The leadership team is committed to following the
guidelines for taking necessary disciplinary or corrective actions
outlined in VA Directive and Handbook 5021, Employee-Management
Relations and the VA Accountability and Whistleblower Protection Act of
2017. Current law regarding Whistleblower Protection has been
incorporated into new supervisory training.
Question 9. How will the Manchester VA incorporate physicians'
input in management of the medical center's programs?
VA Response: Acting Medical Center Director is conducting monthly
listening session with providers and has an open door policy. Medical
Center Leadership conducts monthly conversations with the Clinical
Service Leadership. Service Line Managers are encouraged to hold
monthly meeting with their staff to obtain physician input for those
meetings. Additionally, the Acting Medical Center Director has
introduced a clinical advisory board consisting of all clinical staff
to have input into the decision making process at the Medical Center.
Question 10. What provider professional educational opportunities
exist at the Manchester VAMC?
VA Response: Tuition & related travel support (up to $1,000 per
year) for Continuing Professional Education (CPE) for board certified
physicians and dentists.
Continuing Medical Education (CME) online courses through
SWANK Healthcare.
Onsite CME & Continuing Education Unit programs sponsored
by medical center using the Employee Education System/ederal
Accreditation System process.
Remote access to Morbidity and Mortality Rounds held at
WRJ.
Schwartz Rounds.
Patient Aligned Care Team (PACT, which is VHA version of
Primary Care Medical Home) Training.
Pharmacy training.
Training on Electronic Medical Record.
New Employee Orientation and other mandated training.
Physician Assistant annual broadcast.
Leadership Academy local, VISN, and national level
programs.
Supervisor training through Human Resources if
applicable.
Question 11. Do forums exist for physicians and providers to raise
and address issues concerning clinical operations?
VA Response: Acting Medical Center Director in Manchester is
conducting monthly listening sessions with providers and has an open
door policy. Medical Center Leadership conducts monthly conversations
with the Clinical Service Leadership. Service Line Managers are
encouraged to hold monthly meeting with their staff to obtain physician
input for those meetings. Service Line Managers are encouraged to hold
monthly meeting incorporating physician input into those meetings.
Manchester VAMC is also currently in the process of setting up a
clinical Advisory Board.
Question 12. How are staffing priorities made at the facility and
VISN level?
VA Response: At Manchester, staffing requests with justification
are made by Service Line Chiefs via an automated process through to
their respective senior leaders. A Resource Committee convenes normally
twice per month to review requests for new or modifications to existing
positions. The Resource Committee weighs the workload need and compares
it to the facility budget for affordability, then makes a
recommendation to the Director. Similar processes are generally in
place at other Medical Centers across VHA. VISN offices communicate key
staffing priorities identified by VHA Central Office or VISN priorities
and monitor success in meeting these priorities.
Question 13. Was the Manchester VA leadership incentivized to send
veterans to community providers for treatment via the Choice Program
instead of providing care at the Manchester VAMC as a cost-saving
measure?
VA Response: Choice created a distinct and separate account of
funds that were available when care was provided through the Choice
program. VISNs and VAMCs received specified amounts of discretionary
funds, via the VERA allocation, to provide care at the VAMC or through
the traditional community care program. The new mandatory funding
streamcreated a new structure with different incentives than had
existed before, with the Choice Program funding existing outside of the
facility's allocation.
Question 14. Are facility directors required to report provider
vacancies and plan for new hires and attrition in the plan and budget
for each fiscal year?
VA Response: There is no requirement to report specific vacancies
from a financial perspective, but the VISNs are responsible for
submitting a budget operating plan that includes estimated Budget
Object Code 10 - Personnel Services obligations that should reflect
annual turnover (new hires and attrition). While there is not a
requirement to report vacancies in the manner that is referenced in the
question, facilities are asked to report their vacancies on a monthly
basis for overall position management of VA.
Question 15. How many providers would Manchester VAMC need to hire
to fully restore the cardiology service line?
VA Response: The VAMC is currently in the process of conducting a
full review of the Cardiology Clinic. Simply hiring additional
cardiologists will not guarantee an efficiently managed clinic. The
VAMC is currently engaged with the VA Office of Veteran Access to Care
field service providers to assist in determining access and clinic
utilization issues.
Question 16. What recruiting efforts have the Manchester VAMC taken
to identify a permanent director and hire a new Chief of Staff, and
when does the facility expect to have these positions filled at the
facility?
VA Response: Recruitment for the Director's position is not handled
by the VAMC. The Director's position was posted in October by VA
Corporate Senior Executive Management Office in VA Central Office and
active recruitment is underway. Since the current Chief of Staff
position is still occupied pending conclusion of Office of
Accountability and Whistleblower Protection investigation, the Medical
Center has not yet received permission to begin the recruitment process
for this positon.