A VA Medical Center in Colorado Paused Heart Surgeries for 13 Months. Its Leaders Didn't Tell Higher-Ups.

Heart surgeries were paused at the Department of Veterans Affairs medical center in Aurora, Colorado, for more than a year in 2022 and 2023 as a result of changes made by leaders who cultivated a "culture of fear" at the hospital, the VA Office of Inspector General has found.

Two reports released Monday by the VA's top watchdog found that the facility paused cardiac surgeries from June to July 2022 and again from September 2022 to October 2023. Leadership told their regional directors of the first pause but did not inform them or the VA's Central Office in Washington, D.C., of the second, longer suspension.

The VA OIG said the pauses did not directly contribute to patient harm, but the toxic work environment, explored in a separate investigation, jeopardized patient safety.

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"Senior leaders failed to utilize High-Reliability Organization principles, undermined the stability and psychological safety of service leaders and staff, and created a culture of fear," Dr. John Daigh, the VA assistant inspector general for health care inspections, wrote in a report.

According to the investigations, five adult critical nurse practitioners who worked in the hospital's surgical intensive care unit left in April 2022 as a result of changes made to their jobs by leadership.

Following those departures, the hospital paused heart surgeries for a month, resuming them only after increasing physician coverage of the intensive care unit at night by bringing in the former chief of surgery, former interim intensive care unit director and another surgeon who also worked during the day to provide care.

The facility was forced to pause heart surgeries again two months later after continued efforts to attract permanent personnel failed. During the second pause, the hospital's entire cardiac surgical staff left. The hospital was able to resume procedures only 13 months later after it contracted with the University of Colorado to provide surgical teams.

The staffing issues and changes to the surgical intensive care unit were part of a larger problem investigated by the VA OIG in a separate report also drafted by Daigh. In that investigation, the office found a workplace climate in which leaders belittled staff publicly and dismissed their concerns, leading to resignations and transfers, as well as an environment where staff was unable to express concerns over procedures or patient safety.

"The resulting moral distress has led to an exodus of skilled staff at all levels, which in turn harms veteran care," one employee told OIG investigators.

Shortly after the investigations began, the hospital director and chief of staff were temporarily assigned elsewhere, and two other leaders resigned.

Hospital Director Michael Kilmer was sent to another regional directorate, although his LinkedIn profile still lists him as director and CEO of VA Eastern Colorado Health. Dr. Shilpa Rungta, the former chief of staff, is serving as interim physician adviser to the VA assistant under secretary of health for clinical services.

"VA recognizes that a negative employee culture can have a negative impact on patient experience, and the interim leadership at VA [Eastern Colorado Health Care System] is focused on creating a psychologically safe and healthy environment for staff," facility leaders said in a release Monday.

The Rocky Mountain Regional VA Medical Center is one of the VA's newest, most modern facilities, opening its doors in 2018 five years behind schedule and $1 billion over budget, with a total cost of nearly $2 billion.

Last month, roughly 500 surgical procedures were canceled or delayed at the facility after staff found a mysterious black residue on reusable medical equipment needed for some surgeries.

The exact source of the residue, which appears to be plastic, according to news reports, has yet to be determined but is likely linked to sterilization equipment.

The IG reports made several recommendations to VA leaders at both the local and headquarters level to improve the facility's workplace environment and patient services. Those included a complete review of the facility's operations, staffing, leadership and retention, and a focus on the regional office, known as a Veterans Integrated Services Network, or VISN.

The VA OIG recommended standardization of the VISN directors' roles and responsibilities and an investigation into the circumstances that kept the VISN director in the dark about a 13-month pause in cardiac surgeries.

The House Veterans Affairs Subcommittee on Health held a hearing Wednesday on the VA's regional structure, focusing on its lack of standardization and ability to provide continuity of care.

During the hearing, Dr. Julie Kroviak, the VA's principal deputy assistant inspector general, described the disbelief her office had when they investigated the Aurora hospital.

"When you have that type of exodus of clinical staff, when you have closure of a cardio-thoracic program ... how that noise doesn't make it to the higher level for an immediate intervention, rescue, whatever, our team was appropriately baffled by that story," Kroviak said.

Acting Assistant Under Secretary for Health for Support Services, Veterans Health Administration, Al Montoya assured lawmakers that the VA has responded, with the under secretary of health's office sending a team to Aurora to ensure that the department was "appropriately resourcing" the facility.

"I personally have a staff member out there from my team this week; I'll be personally making a trip out there next month to make sure there is progress, to make sure we are holding them accountable to moving forward," Montoya said.

Sunaina Kumar-Giebel, director of the Rocky Mountain Network, said the facility is committed to "prioritizing a culture of safety."

"Allegations of unsafe patient care or misconduct are taken seriously. These investigations will help ensure veterans, employees and stakeholders have full confidence in the quality and integrity of the leaders and care delivery provided," Kumar-Giebel said in a statement Monday.

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