[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
       
       
       
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        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.