The Rocky Mountain Regional VA Medical Center paused heart surgeries for more than a year in 2022 and 2023 because the Aurora 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.

U.S. Rep. Jason Crow, a Democrat who represents Aurora in Congress, said he was “deeply concerned” to learn of the inspector general’s findings about the Eastern Colorado 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 Department of Veterans Affairs said in a news release that, during the twin year-long investigations, inspectors didn’t find any harm to patients at the Aurora hospital, but the health system’s 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 federal 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 news release said.

Reports of patient safety concerns have gone up in recent months, which shows staff at the Aurora VA now feel more comfortable speaking up, VA Eastern Colorado interim director Amir Farooqi said in an interview Monday. A higher percentage of employees responded to the annual satisfaction survey than in previous years, though they haven’t yet received the results to know whether morale has improved, he said.

“That’s incredibly important when it comes to patient safety,” Farooqi said.

The Denver Post has been reporting since last year on leadership and management issues at the Aurora VA, including:

The removal of the Eastern Colorado VA’s director, Michael Kilmer, and his chief of staff Shilpa Rungta over culture and oversight concerns
The head of the Aurora VA’s prosthetics department directing staff to delete veterans’ orders to clear a backlog; VA officials confirmed to The Post, months later, that more than 1,000 orders were canceled without informing veterans who had sought artificial limbs, hearing aids and other devices.
The reassignment of the Eastern Colorado system’s director of suicide prevention amid allegations of bullying, racism and emotional abuse
Workers’ allegations of an unsafe culture in the Aurora ICU, including the use of COVID-era staffing workarounds long after the public health crisis eased

The two reports issued Monday made a combined 13 recommendations, most of which were directed at higher levels of the VA.They included reviewing oversight of VA health systems; conducting their own review of leadership behavior at the Eastern Colorado system; surveying employees who leave; giving employees ways to share feedback; and ensuring health systems consult relevant staff before major changes.

VA officials wrote that they agreed with all of the recommendations.

Heart surgeries halted due to insufficient staffing

According to the inspector general’s 57-page 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, much longer one.

Staff members told inspectors that a lack of engagement from Rungta in recruiting the people they needed prolonged the pause, according to the report.

During that time, three of the four heart surgery staff 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.

One contracted surgeon told investigators they were uncertain that the hospital had an adequate plan in place to resume surgeries, but Rungta determined it should go forward.

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 VA has been able to determine the residue wasn’t blood or another biological material, Farooqi said. It appears to be some sort of plastic or rubber, and national experts are planning to fly in and help determine where the hospital’s equipment might be breaking down, he said.

“We’re replacing just about everything we can think of,” he said.

The hospital still uses contract surgeons for cardiac procedures, which isn’t uncommon, Farooqi said.

“The important thing is that our patients get taken care of,” he said.

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.

“Widespread disenfranchisement and a culture of fear”

The other inspector general report, on leadership and workplace culture, said more than 50 staff members reported they didn’t feel they could raise safety concerns or report mistakes without retaliation.

The 59-page report specifically called out facility director Kilmer and chief of staff Rungta, as well as the deputy chief of staff for inpatient operations and associate chief of staff for education.

The inspector general “found widespread disenfranchisement and a culture of fear contributed to poor organizational health and numerous resignations by clinical leaders,” according to the report.

Sandra Baker, a retired ER physician who sued the VA in 2022 after she said she was forced out of her job after 32 years, told The Post in November that employees at the Aurora VA were unhappy.

“There’s no way for you to be able to speak up without being harassed or axed — you just have to take it,” she said. “That place is not run by people who have any idea what’s going on in the trenches.”

Some employees told inspectors they felt senior leadership “berated” people who expressed different opinions and made decisions without consulting staff, according to the report. They 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, though inspectors couldn’t determine whether that was their intention. One member said doctors stopped performing high-risk procedures, for fear of punishment if something went wrong. Another compared the process of investigating problems to a “witch hunt.”

According to the report, Rungta said the review process needed changes to ensure doctors were providing safe care. Kilmer told inspectors that concerns about retaliation were “hysteria” and showed resistance to change.

The inspectors sent a survey to 20 people who had previously worked in middle leadership roles, such as heading a department. All reported that lack of trust in senior leaders was one of their reasons for leaving. One said they had seen Kilmer push to have an employee fired for disagreeing with him in front of others.

In some cases, high-ranking positions went unfilled for a year or longer, with the leaders the report cited as contributing to culture problems essentially filling two jobs. The system didn’t have a permanent chief of medicine for at least three years, and went without an intensive-care unit director for more than 18 months. Most positions in clinical leadership have been filled since the inspectors looked in 2023, Farooqi said.

Officials with Veterans Integrated Service Network 19, which oversees VA health care facilities in the region, reported they were concerned about the departures, but didn’t get a full picture of why employees left. Inspectors determined the exit survey links they sent often didn’t work.

The VA told The Post in October that, through potentially temporary reassignments, Kilmer had been moved to the Boise VA Medical Center in Idaho, while Rungta was set to serve as a physician adviser. On Monday, officials wouldn’t say whether the two were still employed by the VA.

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Originally Published: June 24, 2024 at 12:55 p.m.