A veterans’ hospital has been accused of putting heart patients at risk after life-saving cardiac surgeries were paused for a year due to catastrophic staff shortages, multiple investigations have revealed.
Two government probes discovered a ‘culture of fear’ at Rocky Mountain Regional VA Medical Center in Colorado, where leaders were ‘demeaning’ and ‘berating’ to staff, causing more than 20 top doctors, nurses and support staff to leave between 2020 and 2023.
The hospital, which treated more than 100,000 veterans a year, is accused of breaking with protocol for not disclosing the year-long halt on procedures to officials.
One of the investigations shared the case of a 72-year-old man who died from cardiac arrest after an appropriate heart specialist was not available to monitor him.
Regional VA medical center served 101,400 patients between October 2022 and September 2023, the reports found
The investigations, carried out by the US Department of Veterans Affairs Office of the Inspector General (OIG), included interviews with more than 50 former and current employees.
There are 172 VA medical centers and 1,138 outpatient VA sites across the country, providing care to approximately 6.8million veterans a year.
From October 2022 to September 2023, 101,400 of those veterans received care at the Aurora-based Rocky Mountain facility – the same period that OIG investigators focused on.
Concerns about the state of the national VA healthcare system have been around since at least the 1990s, according to a 2023 review from the David Geffen School of Medicine at UCLA and the VHA.
They included criticisms that the quality of care was inconsistent and unpredictable and that services were expensive and difficult to access.
Congress passed an act in 2014 to address some of these concerns – allowing veterans who had to wait more than 30 days for care or lived 40 miles from the nearest VA center to go to local hospitals and have their care reimbursed.
This was followed by a 2018 act that created a long-term reimbursement program for veterans using VA insurance who couldn’t easily access VA hospitals or clinics.
In the Colorado hospital’s case, the reports stated staffing shortages contributed to the year-long gap in heart care.
By 2022 roughly 3.5 percent of all Americans got their healthcare from military programs, down from 4.7 percent in 2015
The first investigation found hospital administration halted heart surgery for the first time in June 2022, after five ICU nurses, critical in monitoring patients who’ve been through heart surgery, quit.
The leadership notified officials about this pause and resumed operating a month later.
But in September 2022, they stopped again. That pause continued through October 2023. During this time, three of the hospital’s four heart surgeons quit and the last was fired.
Throughout this time, however, patients still came in that needed care, but the lack of organization and personnel led to confusion.
Seven providers reported the story of the 72-year-old man whose death was said to be an example of ‘unclear guidance’ from the hospital.
The man was admitted to the ICU department of Rocky Mountain in early 2023 with shortness of breath and an irregular heartbeat. It was soon discovered he was showing signs of heart failure.
The report states two different doctors recommended two different courses of treatment.
The patient quickly declined and went into cardiac arrest, but the ICU staff had no heart specialists in the hospital to address his failing health — and resorted to consulting a cardiologist by telehealth.
Officials from the OIG wrote the patient died despite best efforts from staff in the intensive care unit, who were left to care for the man only on the advice of a telehealth cardiologist.
The report stated that this situation illustrates how ‘unclear guidance’ from administration may have ‘put patients at risk for adverse clinical outcomes.’
An anonymous ICU doctor told investigators the advice the virtual consulting specialist gave was ‘not helpful.’
Later that year, more resignations followed, with the deputy chiefs of anesthesiology, general surgery and mental health all leaving the eastern Colorado hospital.
The second investigation pinned the majority of the cultural issues within the Colorado hospital on four roles – the facility director, chief of staff, deputy chief of staff for inpatient operations and associate chief of staff for education.
In one anonymous interview, a physician told investigators that during a last minute townhall meeting called in 2023, the chief of staff and facility director began ‘just berating us for going outside of the hierarchy…
‘…what was ostensibly a town hall meeting was just them grilling us for reaching outside of our chain of command.’
Investigators concluded the leading staff members created the ‘widespread disenfranchisement and a culture of fear,’ which led to the resignations.
A separate, anonymous psychologist employed at the hospital described distress among staff that had led to an ‘exodus’ of skilled staff at all levels, which in turn harms veteran care.’
Because staff felt they could not voice opinions without fear of retaliation, the report said, they were hesitant to perform risky, but necessary, procedures. Leadership was said to have used reports of safety issues as ‘an avenue to assign blame’.
The 1.2million square foot hospital was completed in 2019. The construction, which cost the Army Corps of Engineers $1.7billion, began in 2014
The OIG report said new leadership staff plans to address these concerns by hosting ‘listening sessions’ to foster a healthier hospital culture, The Denver Post reported.
Sunaina Kumar, the chief executive officer of the VA Rocky Mountain Network, which oversees veterans’ hospitals across Colorado, Oklahoma and Utah, thanked the OIG for its investigation in a public statement.
When asked for a response to commentary for this story, VA representatives told DailyMail.com that Mrs Kumar said: ‘These investigations will help ensure Veterans, employees, and stakeholders have full confidence in the quality and integrity of the leaders and care delivery provided.’
There have been major leadership changes at the organization over the past year, and the report said the interim leaders are addressing these issues.
On a larger scale, the OIG report recommended the federal VHA increase it’s oversight of its hospitals – including conducting leadership reviews, conducting exit interviews with employees and building a feedback system for employees to share concerns.
Local VA leaders, like Mrs Kumar, seem to be in accordance with the change.
‘The VA OIG published two reports that show we have work to do here and I am fully committed to rebuilding trust with the Veterans we serve,’ Mrs Kumar said.
Sunaina Kumar, the Chief Executive Officer of the VA Rocky Mountain Network, thanked the OIG for its investigatio
Even with the increased attention on the national VA healthcare system over the past few decades, there are still national discrepancies between veterans who use VA healthcare versus those who opt for private providers.
In this system, veterans can apply for healthcare benefits through the Civilian Health and Medical Program of the Department of Veterans Affairs.
It covers health care services and supplies for veterans at all VA medical centers – but typically doesn’t cover services offered at outside medical clinics.
Veterans can also still opt to use private insurers for their healthcare.
Veterans who use VA services tend to be less healthy than veterans who use private health care – they have higher rates of cancer, diabetes, hypertension and heart disease, according to a 2015 report from the RAND Corporation, a think tank that advises American public policy.
Also, veterans across the country struggle to get the care they need from VA hospitals. A 2021 survey of 8,670 military families found their chief concern was accessing care from the VA.
Roughly 9.2million veterans are enrolled in this healthcare system, roughly half of all living veterans.
The respondents said troubles scheduling appointments, accessing the correct care and poor quality of care were their main barriers to getting the help they needed.
In a separate 2021 Mission Roll Call survey it was found there weren’t enough appointments available, whether it’s for heart surgery or mental health services, for the 16.5 million veterans living in America as of 2021.
