This story by Lindsey Toomer appeared on Colorado Newsline on June 27, 2024.
Two inspector general reports released this week found that an Aurora hospital for veterans delayed cardiac surgeries for almost a year and created an unsafe work environment for its staff.
The U.S. Department of Veterans Affairs’ Office of Inspector General released a report detailing how leadership failures at the Rocky Mountain Regional VA Medical Center in Aurora led to “a culture of fear” among staff and undermined safety. Another report discussed how intensive care unit changes led to significant delays in veterans’ ability to schedule heart surgeries.
The OIG conducted two separate investigations into how actions from facility leadership affected ICU staffing, patient care, and training for residents. While it found a variety of issues with staffing and ICU changes, the investigation determined that no patients were harmed.
The VA’s Eastern Colorado Health Care System provides services for 100,000 veterans at the Aurora medical center and more than a dozen other locations in the state. U.S. Rep. Jason Crow, a Centennial Democrat and Army veteran who represents Aurora, has expressed his concerns to VA leadership over claims of inadequte care and staffing issues at the hospital. Crow told Newsline he is “very troubled” by the findings of the report.
“We’re glad that the OIG took this seriously and did a very robust investigation, and there’s a lot of work to do to make sure that these things are fixed,” Crow told Newsline. “I’m going to be pushing VA senior leadership in Washington very hard in the months ahead to make sure that remediation is done and that veterans get the care that they deserve.”
Crow said the issues at the hospital have led to veterans waiting longer than they should for primary care and specialty care appointments.
“In a medical context, time is really important, so making sure that we can speed up the process of getting appointments and getting the follow-ups that the veterans deserve is extremely important here,” Crow said.
In June 2022, the hospital notified VA leadership that it could not conduct cardiac surgeries due to “critical” staffing shortages in the ICU and operating rooms. When surgeries resumed in July, staffing was still a concern, with former hospital leadership covering overnight shifts when needed.
Newly appointed hospital leadership paused surgeries again in September, without notifying the VA, and didn’t resume until October 2023. During this pause, the report found all former cardiac surgery staff either resigned or were terminated. The hospital resumed surgery by working with contract staff from the University of Colorado without approval from the VA.
“The OIG found that resuming (cardiac) surgical services after an extended pause met criteria for a major augmentation of clinical services and thus required the approval of the Under Secretary for Health or designee,” the report said. “Further, the OIG found that the absence of a detailed, interdisciplinary evaluation and plan to be very concerning given that the last CT surgery was conducted nearly one year prior.”
Changes in ICU operations and staffing therefore led to a lack of supervision for ICU residents and an ineffective teaching environment, according to the report. The investigation did not find evidence that the changes to ICU operations led to patient harm, though they did lead to significant delays in patients’ ability to schedule cardiac procedures.
The report on hospital leadership and work culture found that high staff turnover came as people from a variety of services across the hospital “felt psychologically unsafe, deeply disrespected, and dismissed, and feared that speaking up or offering a difference of opinion would result in reprisal.” In particular, senior leadership didn’t take staff input into consideration and had “demeaning” communication styles.
While leadership reported improvements in culture, that contradicted accounts staff members shared with the OIG during the same period. The OIG found extended vacancies for several essential mid-level leadership positions at the hospital. All of the recently departed staff the OIG contacted during its investigation reported a lack of trust in senior leadership as a reason to leave their roles.
The reports included a combined 13 recommendations related to oversight from VA leadership, better planning, hiring practices, as well as staff and management training and culture. The VA agreed to all of the OIG recommendations.
Rocky Mountain Regional Network Director Sunaina Kumar-Giebel said the VA takes allegations of improper patient care seriously.
“VA is committed to maintaining excellent patient care and prioritizing a culture of safety,” Kumar-Giebel said in a statement. “These investigations will help ensure Veterans, employees, and stakeholders have full confidence in the quality and integrity of the leaders and care delivery provided.”
Crow said the toxic work culture and dysfunctional leadership affected every aspect of the hospital. While the hospital has gone through several interim directors throughout the OIG investigation, enacting permanent leadership as quickly as possible will help improve the hospital environment, he said.
“It was very clear that the prior leadership did not take staff concern seriously, that there wasn’t a culture that encouraged a free flow of information, reports on incidents and areas for improvement, and of course, that impacted everything at the hospital,” Crow said. “So what needs to happen is the VA needs to make sure that they get senior and permanent leadership.”
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