Manchester VA Medical Center ensures ‘High Reliability’ by empowering veterans and employees

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Manchester’s VA Medical Center is leading the way as the country’s first designated High Reliability Organization. Photo/Carol Robidoux

MANCHESTER, NH – Veterans Administration Secretary Robert Wilkie’s April 19 visit to the Manchester VA Medical Center took place in an atmosphere quite different than the August 4, 2017 VAMC appearance made by former V.A. Secretary David Shulkin.  That trip was a response to a scandal triggered by whistleblowers’ allegations of dangerously substandard care. Shulkin sacked the VAMC’s senior leadership team, appointed Alfred Montoya Jr. as interim director, and announced millions of dollars in new spending on Manchester.

A year-and-a-half later, there is a new Secretary of Veterans Affairs, but Al Montoya is still director, the interim no longer part of his title. Secretary Wilkie came to a much-changed place.

On his mission to Manchester, Wilkie announced the VAMC would be the first veterans health care system to transform into a High Reliability Organization (HRO).  The HRO paradigm uses national standards to bolster patient safety, a main concern for the Manchester whistleblowers.

The choice of Manchester to serve as spearhead in the campaign to improve America’s 17 veterans healthcare systems acknowledges the leadership of Al Montoya and the dedication of the director and his employees. Under Montoya’s watch, the Manchester VAMC has improved its corporate culture.

The HRO paradigm for improving patient safety requires strong bottom-up relationships between employees and senior staff. The V.A.’s response to whistleblowers shows that just such a corporate culture exists at the VAMC and has been strengthened since the scandal.

Wilkie’s trip was preceded by the March 21 visit of Dr. Gerard Cox, the Deputy Undersecretary of Health for the Office of Organizational Excellence. Dr. Cox serves at the Veterans Health Administration, one of three components of the Department of Veterans Affairs, which includes the Veterans Benefit Administration and the Cemeteries Administration.  The VHA oversees veterans medical care.

The VHA Office of Organizational Excellence is tasked with ensuring the quality of care and safety throughout the veterans healthcare system.  Part of their mission is empowering and protecting veterans and VHA employees providing feedback on problems, so that deficiencies can be corrected as soon as possible.

Dr. William “Ed” Kois, right, who blew the whistle on the Manchester VA’s deficiencies, has confidence in the future of veterans care at medical center. Photo/Carol Robidoux

Dr. Cox’s trip featured a roundtable discussion for the media with Cox, Montoya and Manchester VAMC staff members. Afterwards, the press visited Dr. William “Ed” Kois, the head of spinal care, at his office.  One of a group of physicians who sounded the alarm over substandard conditions at the VAMC, Kois was made the public face of the whistleblowers by the Boston Globe Spotlight team.

Dr. Kois said that he believes that the dangerous shortfalls in medical care have been addressed.

A Scandal in Manchester & Its Aftermath

The New Hampshire veterans community was rocked by the Globe Spotlight reports that revealed cutbacks in services and managerial inertia had caused a dangerous decay in the care provided by the Manchester VAMC. Dr. Kois and 12 other physicians had contacted the Office of the Special Counsel, the federal agency that handles whistleblower complaints. They disclosed unsanitary conditions in Manchester, including flies in operating rooms and “sterilized” instruments that were caked with rust or blood.

As the director of care for veterans with spinal cord injuries, Dr. Kois bore witness to the deterioration in the condition of individual veterans due to deficiencies in the care provided them, problems that easily could have been avoided. He also bore witness to the previous Manchester VAMC administration’s failure to correct the deficiencies.

Finding that the allegations most likely were true, the Office launched an investigation at the beginning of 2017. However, the director and chief of staff, Danielle Ocker and James Schlosser, still refused to act to improve conditions.

During Secretary Shulkin’s August 2017 visit, Ed Kois and other whistleblowers held a private meeting with him. Shulkin asked the whistleblowers whether they intended to file a lawsuit under federal whistleblower statutes and seek monetary compensation.  The whistleblowers surprised the V.A. Secretary when they said they had no intention of doing so. Their intent was to improve the Manchester VAMC.

Kois told reporters he was  “cautiously optimistic” after the Shulkin meeting. “We want better care for the patients.”  Eighteen months later, Kois again spoke to the press after the March 2019 roundtable.

“It’s been an incredible journey,” he said.

A Partnership to Create High Reliability

Siting on a chair in his office with Director Montoya standing next to him, the camaraderie between the two was evident.  “When we started this, I was able to get 13 physicians together to try to effect some change, hopefully in a positive way,” Kois said. “It went beyond what many of us expected.”

Manchester VA Medical Center Director Alfred Montoya Jr., left, and Dr. William “Ed” Kois, right. Photo/Jon Hopwood

Kois said that the 2017 Shulkin meeting was productive. “The thing that really amazed us was how open the V.A. was to listen to our stories. I wasn’t sure if they were going to shoot us, or take me for a ride somewhere, but none of that happened.”

The actions of Shulkin and the V.A. were “brilliant,” Dr. Kois said. The key to the success of transforming the Manchester VAMC was bringing in the right people at the right time.

“We didn’t need a club to hit us over the head. We needed someone to listen to what our story was and to try to effect positive changes,” Dr. Kois said.

Things improved after Al Montoya and interim Chief of Staff Dr. Brett Rush were “parachuted” into Manchester, followed by Dr. Paul Zimmerman as permanent chief of staff. “I don’t think it could have been a better group of people that came to listen to us.”

“I feel proud of what happened,” Kois said.

The whistleblower explained, “I didn’t do it to get a better parking space, or corner office, or settlement. I did it because I felt there was a failing in the evolution of medical care at the V.A., and as a physician I was in the right place at the right time to effect some change. And that’s what we’ve seen. After they listened to our issues, we got action.”

The new HRO paradigm to promote safety is part of the positive evolution of veterans healthcare in Manchester.  “Whether it is talking to the guard who greets people at the door or the people who work in the cafeteria, people throughout the facility have noticed a difference,” Kois said. “Veterans have noticed a difference.”

Al Montoya talked about going on a journey with Dr. Kois and other Manchester VAMC employees. “I can’t think of a better partner,” he said. “I consider Dr. Kois a friend.”

Dr. Gerard Cox, left, Deputy Undersecretary of Health for the Office of Organizational Excellence, thanks Dr. William “Ed” Kois, for his steadfast dedication to veteran healthcare. Photo/Carol Robidoux

Noting his frequent visits to Kois’ office, he joked, “I’m down here a couple times a week, so that he can’t cause trouble any more.” A laughing Dr. Kois retorted, “That’s a technique” Montoya uses for managing VAMC employees

“We’re partners in taking care of veterans and taking care of each other. That’s what we want to do,” Montoya said.  “We have 900 employees dedicated to making sure our veterans get the best care. We can’t do that if we stifle ideas. We can’t do that if we say, ‘I’m not going to listen to our employees.’”

As the head of the facility chosen to pioneer the new High Reliability Organization paradigm, Montoya was asked the meaning of high reliability.

“High reliability is what it’s all about,” he said. Creating a strong, steadfast culture of patient safety was dependent on engaging and listening to all employees, be they physicians, nutritionists or housekeepers.  The empowerment of employees made positive change possible in Manchester. It was what saved the medical center, and made it successful.

“People are ripe for change,” Kois said. “People in the trenches are ripe for change.”

Both Dr. Ed Kois and Director Al Montoya are confident that changes transforming the Manchester VAMC will give veterans a reason to choose it as their healthcare provider.


Jon Hopwood is a Manchester-based writer and U.S. Army veteran whose work focuses primarily on cinema, current events, and politics. When not hosting “Ward 13” on  Manchester Public TV or appearing as a guest on 95.3 FM’s “Matt Connarton Unleashed” radio show, Jon progresses steadily, composing his book about the New Hampshire Primary.