The Hippo


Jun 27, 2019








Alfred Montoya. Courtesy photo.

Stepping in at the Manchester VA
Acting director talks about problems, improvements

By Ryan Lessard

What is your background before working for the VA? I understand you are a veteran yourself?

I am. I was a Russian cryptologic linguist for the United States Air Force for 10 and a half years. … For my last tour of duty, I flew on the EC-130H, which is the Compass Call. It’s generally used for jamming and weakening. It was around that time in 2008 that I was medically separated from the Air Force and started transitioning over to the East Coast. My last assignment was actually Tuscon, Arizona, but I found myself relocating to the East Coast with my wife, who got a job as a professor at the University of Connecticut. 
Most recently, you were heading the White River Junction VA. So far, what are some of the biggest differences you’ve noticed between the two facilities?
Well, I think there are a number of differences. When I went to White River Junction in November of 2015 … [I] inherited a medical center that was a high-performing medical center doing a lot of great things with innovation and making sure that they were increasing services in the community. ... I think there are some very big similarities between the two organizations in that there are a lot of great, hardworking staff here at the Manchester VA as well. I think what I see as differences [are] in some cases the processes in which the work is done is a little bit different. So I’ve certainly tried to take some of the processes that we’ve put in place in White River Junction to make sure that our veterans get quality access to care and timely access to care and that our employees also have a good experience, and really kind of duplicate those here at the Manchester VA. Now, I realize I’ve only been here for three weeks and during that three-week time period we also had a flood that was very catastrophic in nature.
Yeah, I’d like to ask you about that. [It happened] just a few days after you came to Manchester. ... How big a deal was this?
That was a huge deal. And I will tell you that I was [awakened] that morning — it was Wednesday the 19th — by our administrative officer on duty by a phone call, essentially saying, “Mr. Montoya, there’s water coming from the seventh-floor mechanical space. We think you should come in.” Luckily, I was just about five minutes away or so from the medical center and was able to come in rather quickly, but when I arrived on the scene, myself and the chief engineer walked floor by floor to survey the damage, and at that point, I realized how catastrophic it really was. Essentially, there was a brass pipe up on the seventh floor … that, due to age and corrosion, had essentially failed. And the water, which is upward of thousands of gallons of water, went rippling through the entire building all the way to the second floor. So as far as operations at the medical center, it really crippled us for quite some time.
Where do things stand with that now?
Due to the quick response of both our contractors in the area as well as other contractors who we had here on site, we were able to mitigate the amount and the extent of damage that was done. Now, don’t get me wrong, there was a considerable amount of damage on the fourth floor. It was hit the hardest. That’s our floor that has the same-day services, the operating room as well as the postanesthesia care unit, as well as some other surgical clinics. That area was hit the hardest and we expect that to be out of commission until probably at least 1 December, or right around the December timeframe. … We’re slowly starting to open up different areas of the hospital. Our most recent addition was our optometry and audiology area as well as our mental health group rooms. In the interim ... we’ve been able to mobilize several mobile medical units, which are essentially RVs with exam rooms in them, as well as some mobile vet centers from across the country, to be able to provide those services in a different environment.
Why do you think you specifically were chosen to step in at the Manchester center, at least for the time being?
I think for me, as the director of the White River Junction Medical Center, I share many of the same congressional stakeholders as well as many of the same veteran service organizations. So, most of our stakeholders I know, first hand, and I can relate to them. I think having that relationship already in place certainly helps us move forward as an organization and also helps us move forward and also improve on the things that need improvement.
The Boston Globe report that triggered your placement and the ongoing investigation reported a number of issues such as a fly-infested OR and cases where lack of care allegedly resulted in preventable spinal damage. Have you ever heard of issues like this happening at any VA in your years of experience?
I can tell you that I’ve actually been in the VA since 2009. I think that certainly this is one of the reasons — that the allegations that were outlined in the Boston Globe article is certainly why the secretary ordered a top-to-bottom review of the Manchester VA Medical Center. And I think along with that came the investigators from the office of the medical inspector as well as the office of accountability and whistleblower protection as well as several different teams from the health care improvement center, within VA. So I think there have certainly been a number of resources on the ground, to be able to identify actions for us to take as a medical center and really help move us forward from where we were. … I think that we’re faced with challenges across the system but … I’m focused on moving us forward on the improvements that I see now and not really looking back on the past.
Aside from the many concerns, what do you think are some of the areas the Manchester VA is doing well in?
I think the flood and having all of our employees come together to work together as a team was certainly a bright spot for me, to see our employees coalesce around that. It really warmed my heart to see that our veterans and our staff were so understanding of what was happening. … I’m hearing from a lot of our veterans that there are a lot of veterans who have … shared accolades about the care that they received in Manchester. So what I am doing is I’m sitting here listening. I want to hear both sides of the story. I want to make the improvements on both ends. … I would like to talk about some of the improvements that we’re currently undergoing.
One of the biggest components that I heard from our veterans when I got here was the way that Choice, or the Choice program, was facilitated here at the Manchester VA Medical Center. [Editor’s note: Choice is a program that is meant to enable veterans to receive care from providers outside the VA system who are then reimbursed by the VA.] ... I’m a firm believer of doing things differently and getting different results, instead of just trying something over and over and over again and getting the same result. In this case, particularly, what we essentially did was establish a service line in and of itself called the Office of Community Care. That office … is actually going to be led by a physician provider who will report directly up to the chief of staff. … Underneath that physician leader, essentially there are … case management teams that are led by nurse case managers and they have choice champions or support individuals underneath them to help navigate the Choice process. So we’re very quickly standing that office up to be very forward-facing to help our veterans. What we’ve found with this case management approach is it does three things. It helps us in actually ensuring our veterans can navigate the Choice process; it also helps our providers out in the community — which has been another complaint that I’ve heard about — be able to elevate the concerns that they have about billing or anything in that nature. But it also helps us do outreach in the community and essentially establish certain provider agreements with individual providers that we may not have already. … Similarly, I think this flood that occurred on that Wednesday also allowed us to really start thinking outside the box. One of the ways that we do that is, on average, we have 30 to 40 endoscopies that are done here in Manchester every single week. If you can imagine, with the fourth floor, which housed all of the endo-services, being out of commission until December, that’s quite a bit of veterans who are impacted by the lack of endoscopy services. So essentially what I did is I had a number of community clinical partners reach out to me and I … [started] having active discussions with CMC, the Catholic Medical Center, and Alex Walker, who is their COO down there. And we essentially have set up what we find to be very unique in our opinions. … It’s essentially setting up a Manchester VA at CMC. They were gracious enough to allow us to use one endoscopy suite and we’re essentially using our staff now, who are displaced due to the flood, to go over to that endoscopy suite and perform the endoscopies for our veterans. And we’re due to actually have that kick off on Thursday [Aug. 10].
What are you hearing from veterans who use the facility for their medical care?
I’ve had the opportunity to host a town hall myself to hear the concerns of our veterans as well as attend the whistleblower town hall that was hosted last week. Similarly, I was out in the community talking with our veterans and trying to get out there and listen as much as possible. And I think that the No. 1 concern … is that our veterans are frustrated with Choice and the Choice process. ... I think that our veterans are also frustrated by not having certain services here at the Manchester VA Medical Center, which is one of the reasons why … [we’re creating a] task force with identifying the future of the Manchester VA, to really look and see what full services could be engaged here. What does it look like? What does it feel like? Is that a full-service hospital? If so, how do we do that? Is it a public-private partnership? I think it allows us an opportunity to really think outside the box here. ... I think part of my job is really to make sure that I’m listening to our veterans and getting out there and hearing what they have to say and coming back and doing something with it. That’s something that I pride myself on tremendously, being a veteran myself who was medically separated, who gets 100 percent of my care in the VA.
What are you hearing from staff about ways to improve the facility?
I’m certainly hearing from our staff the need for more constant communication and involvement in all processes throughout the organizations. … I personally have been holding listening sessions with our staff. … The Manchester team together, all of us can do really great things if we’re all pointed in the right direction and running, charging at that. ... I think to get there, we have to listen, we have to communicate and we have to actively involve both our veterans and our staff.
— Ryan Lessard  

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