The Rocky Mountain Regional VA Medical Center paused heart surgeries for nearly a year between 2022 and 2023 because the hospital didn’t have the staff to care for those patients after their procedures — and never told the federal Veterans Health Administration, as required.
Two new reports released Monday by the U.S. Department of Veterans Affairs’ Office of the Inspector General detailed the surgical pause, which hadn’t been previously reported, and investigators’ findings that the VA Eastern Colorado Health Care System’s leadership created a “culture of fear” that compromised patient safety.
Rep. Jason Crow, a Democrat who represents Aurora in Congress, said he was “deeply concerned” about the inspector general’s findings about the Aurora-based Eastern health system.
“Veterans take an oath to serve and are promised quality care when they return home,” he said in a statement. “I appreciate the OIG’s thorough investigation and will continue to push the VA to make all necessary changes to ensure veterans receive the quality care they deserve.”
The VA said in a news release that inspectors didn’t find any harm to patients, but new leaders have taken steps to fix the problems, including holding “listening sessions” with staff about culture concerns, creating a tool for employees to offer feedback and accepting additional oversight.
“VA recognizes that a negative employee culture can have a negative impact on patient experience, and the interim leadership at (the Eastern Colorado system) is focused on creating a psychologically safe and healthy environment for staff,” the release said. “We appreciate the work of the Office of the Inspector General, which helps us better serve our nation’s veterans, and we fully agree with the OIG’s recommendations.”
According to the report on the surgical pause, five nurse practitioners who provided intensive care to patients who’d had heart surgery left in April 2022, meaning the Aurora hospital could no longer provide around-the-clock critical care to those patients. People who’ve had complex procedures, such as open-heart surgery, often need to stay in an intensive care unit during the first phase of their recovery.
The Aurora hospital initially paused heart surgeries for one month, starting in mid-June 2022. The medical center temporarily resolved the situation by having three physicians chip in to cover the intensive care unit, but paused heart surgeries again from September 2022 to October 2023. The hospital notified the VA Central Office of the first pause, but not of the second, longer one.
During that time, three of the four heart surgeons employed by the hospital chose to leave, and the remaining one was fired. The VA hospital then had to contract with University of Colorado Hospital to borrow its surgeons so it could start offering heart procedures again.
The pause on heart surgeries is unrelated to the current situation at the Aurora VA, where, as of last week, more than 500 surgeries had been postponed or moved elsewhere since April due to an unidentified residue that has been discovered on surgical equipment at the hospital.
The inspector general’s report also found that a change in the intensive-care unit from an “open” to a “closed” model interfered with medical residents’ education, though it didn’t find evidence of harm to patients.
In a closed unit, a physician who specializes in intensive care is primarily responsible for patients, while in an open unit, other specialists remain in charge of the patient’s care, and consult the intensivist as needed. Some studies have found fewer patients die in closed units, though more research could confirm or refute that.
The OIG didn’t issue an opinion on whether switching to a closed model was the right decision, but said leadership rushed the transition. As part of the change, medical residents who were monitoring ICU patients overnight no longer had on-site supervision, but had to call a telehealth line if they had questions. Residents reported they worried they wouldn’t be able to care for patients safely under those circumstances.
The other inspector general report, on leadership and culture, said more than 50 staff members reported they didn’t feel they could raise safety concerns or report mistakes without retaliation.
Some employees also said they felt senior leadership “berated” people who expressed different opinions, or made hasty decisions without considering staff concerns. They also described departments losing resources in retaliation for their employees speaking up and investigations that were “weaponized” to punish specific people, rather than focusing on finding the truth.
Members of a committee assigned to review mistakes and safety concerns said senior leadership took over its meetings and used them to “target” physician groups. One said doctors stopped performing high-risk procedures, for fear of punishment if something went wrong.
The chief of staff, who was on the committee, said the process needed changes to ensure doctors were providing safe care. The facility director told inspectors that concerns about retaliation were “hysteria” and showed resistance to change.
This is a developing story that will be updated.
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