New reports released this week following a pair of investigations detail a “culture of fear” and an “extended pause” in cardiac surgeries at the Rocky Mountain Regional VA Medical Center in Aurora.
The reports blame since-departed top leaders there that investigators say undermined patient safety.
Inspectors with the U.S. Department of Veterans Affairs Office of Inspector General conducted the review and prepared the reports.
“I'm appalled, frankly, that there were delays in appointments, cancellation of appointments, and other issues that veterans shouldn't have to go through,” said Rep. Jason Crow, a Democrat from Aurora, in an interview. The facility is in the district he represents.
“The problem here is that there was senior leadership that was hiding problems, creating a toxic work environment,” he said. “Not listening to the concerns of staff and the health care workers, and that impacted almost everything at the hospital and within the region.”
In a press statement in response, the VA said inspectors “did not substantiate” any harm to patients.
“However, VA recognizes that a negative employee culture can have a negative impact on patient experience,” the release said, noting interim leadership at VA Eastern Colorado Health Care System “is focused on creating a psychologically safe and healthy environment for staff.”
“VA is committed to maintaining excellent patient care and prioritizing a culture of safety. Allegations of unsafe patient care or misconduct are taken seriously,” said Sunaina Kumar-Giebel, network director of the Rocky Mountain Network. “These investigations will help ensure veterans, employees, and stakeholders have full confidence in the quality and integrity of the leaders and care delivery provided.”
The release said interim leadership had taken steps in response to the crisis, including holding "listening sessions" and implementing new oversight measures. They say the changes are “aimed at fostering a culture of openness, inclusivity, and continuous improvement within the organization.”
Heart surgeries put on hold due to staff shortages
The report on the pause in cardiac surgeries details problems starting in spring 2022. That’s when “facility leaders implemented staffing changes that adversely affected the provision” of cardiothoracic (CT) surgeries in the surgical intensive care unit “without adequate planning.”
In April of that year, five ICU nurse practitioners either transferred to another service, resigned, or retired, “reportedly due to unfavorable changes” to their schedules. The report says that resulted in limiting the medical center’s ability to provide 24/7 care for those patients, so those surgeries were paused while the facility tried to hire providers to replace them.
From mid-June to mid-July 2022, the facility's former chief of staff paused cardiac surgeries due to “critical staffing shortages” in the ICU and operation room. The surgeries resumed with new coverage plans in place as three doctors stepped in to provide coverage, although facility leaders noted staffing was still a concern.
Just a few months later, surgeries were again paused in September 2022 for more than a year, until October 2023. According to minutes of the Surgical Work Group at the hospital, efforts to secure proper staffing were unsuccessful, so surgeries were halted.
“During that time, all former CT surgical staff had either resigned (three) or were terminated (one),” according to the report.
Inspectors said they found the staffing shortage and pause “ultimately led to (the) loss of all facility cardiac surgical staff.” The medical center eventually hired contract staff from the University of Colorado to resume surgeries.
The report documented another problem revolving around a change in the way the intensive care unit is structured, moving from what’s called an “open” model to a “closed” one.
In the closed model, an intensive care specialist is mostly in charge of patient care; in the open system other specialists take the lead and consult with the intensive care physician.
The report said the Inspectors General’s Office got a complaint that leaders switched the medical ICU from an open to closed unit, “without appropriate planning or discussion” with ICU leaders and staff. The complaint alleged that led to a lack of supervision and an ineffective teaching environment.
Inspectors found the change disrupted patient care and the education of medical residents. The change “resulted in a lack of ICU resident supervision and an ineffective teaching environment for residents,” the report stated. But it noted they could find no evidence of harm to patients.
The Office of Inspector General “did not substantiate that the medical ICU model change resulted in patient harm.” It did identify, however, what it called a “deficiency” in what’s called “root cause analysis,” a deep dive to understand the issues driving the problems. That included differing reports from staff and findings being made without interviewing relevant providers.
In a statement, VA said it is taking multiple steps to address the concerns raised in the report. They include:
- Ensuring that policy compliance, procedures, and improved communication pathways are in place and complied with, so that facility leadership are aware of pauses in clinical service lines within its network.
- Utilizing lessons learned to ensure that all appropriate employees, including service chiefs, section chiefs, and frontline employees are involved in the planning, coordination, and communication of clinical operation changes.
- Collaboration between the VA Eastern Colorado Health Care System and VA’s national Office of Academic Affiliations to ensure that a strong medical education program is maintained and impacts on trainees are closely evaluated during clinical program changes.
The facility has been wrestling with other surgical troubles in recent months, unrelated to the staffing issues documented in the new reports.
Four hundred surgical procedures and 100 dental procedures have been rescheduled to other facilities or postponed since April due to black plastic residue found on hospital surgical equipment. Officials believe the source was a reusable medical device washer used to sterilize reusable medical equipment.
Experts, including from Steris, the company that makes the equipment, have been at the facility trying to figure out the cause and how to fix it.
“It can be a challenging situation because it is complicated and because the standards are high as they should be, but we really are trying to bring in everybody in every way,” said Amir Farooqi, VA Eastern Colorado Health Care System interim medical center director, in an interview last week. “So our hope is that it doesn't last too much longer.”
'An environment that undermined the culture of safety'
Inspectors examined the work environment in the second report, detailing a litany of culture and staffing problems.
They did an inspection to assess allegations senior leaders failed to practice what are called “high reliability organization principles” and “created a culture of fear” at the VA Eastern Colorado Health Care System in Aurora.
Inspectors substantiated the allegations and described the problems in scathing language, finding key senior leaders created an environment that undermined the culture of safety. “A significant number” of clinical and administrative leaders and frontline staff, from a “multitude” of departments, said they “felt psychologically unsafe, deeply disrespected, and dismissed, and feared that speaking up or offering a difference of opinion would result in reprisal.”
The addition of two key senior leaders to a peer review committee in 2023 didn’t help, the report says. The culture of the committee changed to an environment perceived by six committee members as well as other leaders and staff not on the committee “to be psychologically unsafe and punitive.”
“When learning of concerns, key senior leaders missed opportunities to understand concerns and make efforts to foster a psychologically safe environment,” the report states.
The report goes on to document other leadership issues. Inspectors found “mid-level leadership had been eroded and three key senior leaders held a monopoly of control.”
They described resignations and extended vacancies, including among clinical staff.
A number of former leaders quit, saying a “psychologically unsafe work environment was a major factor in their decision to leave,” according to the report. “Despite these losses, key senior leaders did not seek or utilize employee exit survey data to identify and address employee retention challenges.”
In response, the VA issued a statement, saying “we appreciate the Office of the Inspector General’s (OIG) review and take their findings very seriously.”
“Ensuring that all VA employees work in an environment where they are supported, feel comfortable to raise concerns, and know their concerns will be taken seriously is of paramount importance,” the release said. “We concur with the OIG’s recommendations and have taken numerous actions to address the findings in this report.”
It noted the facility has expanded tools for employees to share feedback, increased the frequency of local employee town halls, revamped daily staff huddles, and “made it a priority to focus on promoting inclusivity and continuous improvement” among staff.
Recommendations
The pair of reports made more than a dozen recommendations. Those included senior VA leadership conducting a review of oversight of VA Eastern Colorado Health Care systems and leadership actions, improving employee feedback and using surveys of employees who leave to “identify challenges with employee retention.”
A top VA official agreed with the recommendations and provided a plan to address the problems.
“We are committed to addressing all issues identified in the OIG’s report and are grateful for the dedicated workforce at the Eastern Colorado VA who work tirelessly every day to provide Veterans with the world-class, timely high-quality health care that they deserve,” the regional VA wrote in its release.
