Draft report finding little wrongdoing at Manchester VA met with skepticismBy TODD FEATHERS
New Hampshire Union Leader
September 23. 2018 10:37AM
MANCHESTER - For the fourth time, a draft report from the U.S. Department of Veterans Affairs' investigation of alleged unsanitary conditions and poor patient care at the Manchester VA Medical Center has been met with widespread skepticism, prompting lawmakers to reiterate calls for congressional hearings.
Like three previous draft reports from the VA's Office of the Medical Inspector (OMI), the latest report includes few findings of wrongdoing and largely exonerates the hospital's previous administrators, who were reassigned after a group of doctors came forward to The Boston Globe with concerns last July.
"I'm just astounded and disgusted. I can't even believe - they made this thing look like some sort of farce that had no basis in reality," said Dr. Ted Daly, who stepped down as chief of radiology out of frustration with the hospital's administration. He still works at the Manchester VA. "It's almost like the people who wrote this investigation didn't even care what any of us had to say and had pre-ordained thoughts about what the outcome was going to be."
Dr. William "Ed" Kois, who was also one of the whistleblowers, described the draft report as a "whitewash" of patient neglect that had devastating consequences for veterans with spine conditions. The VA's inability to admit mistakes, he said, is part of the reason the agency is constantly embroiled in scandals.
"I compare the VA system to the Galapagos Islands, where you had species that hadn't existed in the rest of the world for 500 years still dominant because they hadn't evolved. (The VA) hasn't evolved with the rest of the systems," Kois said.
In the latest draft, a copy of which was obtained by the New Hampshire Union Leader, OMI's investigators substantiated claims made by whistleblowers that a contractor failed to arrange appointments for thousands of veterans with specialists outside the VA system through the Veterans Choice Program.
The VA's contract with that vendor, Health Net Federal Services, will end Sept. 30.
Investigators did not substantiate allegations that:
. Dozens of patients with spinal conditions weren't given proper care;
. Hospital administrators stymied doctors' ability to refer patients to specialists through a different program;
. Procedures had to be canceled in an operating room because it was infested with flies (investigators did, however, determine the room had a fly problem);
. Surgical tools in another room were contaminated (discoloration on the instruments was blamed on Manchester's water supply);
. Hospital administrators were unresponsive to the medical staff's concerns.
"The OMI report thoroughly investigated the concerns regarding the Manchester VAMC, and the findings speak for themselves," Maureen Heard, chief communications officer for the New England VA system said. "The Manchester VA Medical Center is under new leadership and on a new path and has taken a number of steps to rebuild trust, improve care and provide better service to New Hampshire area veterans."
After seeing the OMI's latest draft, Rep. Ann Kuster, D-N.H., who sits on the House Veterans Affairs Committee, reiterated her call for a hearing into the management of the Manchester hospital and the VA's ability to investigate itself.
"I object to the conclusions in terms of the quality of care for those patients in this report," she said, adding, "I think they have every reason to sort of paper over the failures. ... I would like the secretary to come and meet with everyone and tell us if they stand by this report."
Both she and Andrea Amodeo-Vickery, the Manchester attorney representing the whistleblowers, said they would like the Office of Special Counsel to once again instruct the VA investigators to do a better job.
After the third draft report, the OSC, an independent federal agency that investigates cases brought by whistleblowers, wrote a letter to President Donald Trump stating that the VA's conclusions were inconsistent with the evidence and that investigators "were frequently evasive in their reluctance to acknowledge wrongdoing."
Perhaps the most frustrating aspect of the situation, Kois said, is that the Manchester VA's new leadership has overseen a dramatic improvement in quality and morale, yet the upper echelons of the agency refuse to acknowledge all the problems that existed in the first place.
The hospital has, for example, addressed one particularly concerning allegation Kois and other doctors made: that patients with spinal conditions were becoming unnecessarily wheelchair-bound because the New England VA system wasn't providing the surgical treatments and patient follow-ups that are the standard of care at other hospitals.
Now, the Manchester VA is efficiently referring those patients to outside specialists, according to Kois and Al Montoya, the hospital's new director.
The Manchester VA has hired more medical staff, reduced the waiting period for veterans to see a primary care physician from around 75 days to 16 days, and substantially improved employee morale, Montoya said.
"Our work of improvement is not done," he said. But "over the course of the last year, we have been investing in the organization, investing in the veterans of New Hampshire."