My Turn: The road forward at the Manchester VA

For the Monitor
Published: 8/30/2017 12:15:02 AM

Sometimes things get worse before they get better. The whistleblowers and the VA administration have each been following parallel paths with hopefully the same goals in mind.

The whistleblowers have been meeting with the New Hampshire congressional delegation in an attempt to expedite the needed improvements and assure the integrity of the investigation. Meanwhile the administration has been preparing the roll-out of their roadmap for improvement. This culminated with town hall meetings and presentations from the network director. One thing that is universally agreed upon is that solutions must be enacted soon.

Conditions at the Manchester VA may be worse now than they were before the Boston Globe article was published. The burst pipe was certainly a contributing factor, but it is not an excuse for further lapses in care. Patients are at risk, and unless steps are taken soon, patients could be endangered.

The reasons for the increased risk to patient safety are actually quite obvious. The removal of top leadership, i.e. director, chief of staff, and later the nurse executive, while long overdue, has created a serious supervisory vacuum. The problem was further exacerbated by the removal of the business office director, Gary Von George. This removal was an act of retaliation for his criticism of the administration with regard to the beleaguered Choice Program. One can only imagine how bad the Choice program can further slide with the loss of one of the few competent administrators. The above vacancies only added to the nascent leadership at the medical center created by the loss of the chiefs in surgery, primary care, urgent care and medicine. It is only through the dedication of the VA staff that quality care continues.

I believe honest attempts have been made by Acting Director Al Montoya and his team to fill this void but it would be unrealistic to expect they could do so while splitting their time between Manchester and White River Junction. Just last week procedures were again canceled when questions arose as to the suitability of using radiology suites for endoscopy. Experienced leadership would have checked out the space more carefully before scheduling patients.

The effort to reinstate the use of the old nuclear medicine equipment until the new camera is installed has also languished. As has been shown, the closure of the nuclear medicine program has delayed care for many veterans.

Filling the leadership void has been mired in red tape. While the process of hiring for a new nurse executive has begun, the other top leadership positions have not yet been posted. The reason given is that the nurse executive formally applied for retirement but the former director and former chief of staff are still working at another medical center. There exists the specter that they may even be reinstated. Management considers it wasteful to hire for positions that haven’t been formally vacated. Their concern is not entirely without merit, since the VA is rarely able to rid itself of its poor performers.

While the entire N.H. congressional delegation has thus far unsuccessfully pushed for my being included in the task force to study a full-service medical center, a former problematic medical center director who left Manchester will be included in the process. The consternation expressed over this and the ensuing debate has led to delays in empaneling this task force. Attempts have been made to expedite care, including the signing of an agreement with Catholic Medical Center. Even the governor has gotten involved by signing an executive order to reduce the time required for VA physicians to obtain a N.H. medical license. VA employees do not need to have an in-state license to treat VA patients at a VA facility.

Last Wednesday, Dr. Michael Mayo-Smith, the network director, began holding stakeholder meetings detailing the path forward. He emphasized that the time for fault finding has past. It is time to start solving problems. He detailed broad categories of problems that needs to be addressed.

One of the areas mentioned was bureaucracy. On this the whistleblowers are in complete agreement with him. The old hidebound bureaucratic thinking that got the VA to where it is now just won’t suffice. Problems must be addressed in a new, innovative manner.

Bureaucracy seemed to be a thread that ran through all the categories he listed for improvement.

Rebuilding leadership was a category that went beyond filling the aforementioned leadership openings. It included creating a “Care in the Community” coordinator position. This has been a position touted by Montoya for addressing the issues with Choice.

Fixing Choice was a category unto itself. In our meetings with the congressional delegation the problems created with the hasty passage of Choice legislation were well known. New legislation is coming. Perhaps this time a better bill will be crafted. It is my view that Choice cannot be fixed. Veterans would be better served by directing the money into the new Care in the Community office. Healthnet, the company that is responsible for so much of the misery created with the Choice program, should be abolished.

Dr. Mayo-Smith discussed restoring the cardiology program to its previous levels. He also discussed adding new primary care teams. No one could disagree with either of these efforts. Hiring a second suicide prevention coordinator was also discussed, although many feel this alone will not impact the tragedy of veteran suicide.

A discussion of the Full Service Hospital Task Force was included under the moniker of “Designing the Future.” It was stated that it was unlikely a new building would be built to replace the old dilapidated main building. Dr. Mayo-Smith acknowledged that these old buildings are often cheaper to replace than to keep repairing over and over again. The incremental spending may at some point equal the cost of rebuilding. This was echoed in our meetings with Congress. The VA must prove it is able to replace aging infrastructure in an efficient manner. It is believed in many circles that the VA lacks the resolve to build another medical center due to its long string of failures in its recent efforts.

Implementation has long been the VA’s Achilles heel. My colleague Dr. Ed Kois is a champion of making the Manchester VA a model for the delivery of 21st-century medical care for veterans. Unless the VA can demonstrate a renewed ability to replace its outmoded infrastructure, the new model is likely to be privatization. This is not the model that either Dr. Kois or myself envision.

Hopefully, with continued efforts, the unique opportunity for improvement that is present at the Manchester VA won’t be wasted. The coming weeks may show that this past week was a turning point. Let’s all hope it’s turning in the right direction.

(Stewart Levenson is a rheumatologist who advanced to become the chairman of the medicine department at the VA in Manchester. Three years ago, he was named medical director of the New England VA network. He lives in Hopkinton.)

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