A VA hospital has been accused of putting heart patients at risk after life-saving heart surgeries were put on hold for a year due to catastrophic staffing shortages, multiple investigations have revealed.
Two government investigations uncovered a “culture of fear” at the Rocky Mountain Regional VA Medical Center in Colorado, where leaders were “degrading” and “berating” staff, prompting more than 20 doctors, nurses and staff high-level support will leave between 2020 and 2023. .
The hospital, which treated more than 100,000 veterans a year, is accused of breaking protocol by not disclosing to officials the suspension of procedures for a year.
One of the investigations shared the case of a 72-year-old man who died of cardiac arrest after a suitable cardiologist was not available to monitor him.
VA Regional Medical Center Served 101,400 Patients Between October 2022 and September 2023, Reports Show
The investigations, conducted by the U.S. Department of Veterans Affairs’ Office of Inspector General (OIG), included interviews with more than 50 current and former employees.
There are 172 VA medical centers and 1,138 VA outpatient sites nationwide, providing care to approximately 6.8 million veterans annually.
From October 2022 through September 2023, 101,400 of those veterans received care at the Aurora-based Rocky Mountain facility, the same period OIG investigators focused on.
Concerns about the state of the VA’s national health care system have existed since at least the 1990s, according to A review of 2023 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.
In 2014, Congress passed a law to address some of these concerns, allowing veterans who had to wait more than 30 days for care or who lived within 40 miles of the nearest VA center to go to local hospitals and receive reimbursement. of your attention.
This was followed by a 2018 law that created a long-term reimbursement program for veterans who used VA insurance and could not easily access VA hospitals or clinics.
In the case of the Colorado hospital, reports indicated that staffing shortages contributed to the one-year gap in cardiac care.
By 2022, about 3.5 percent of all Americans will get their health care from military programs, up from 4.7 percent in 2015.
The first investigation found that hospital administration first stopped cardiac surgery in June 2022, after five ICU nurses, instrumental in monitoring patients who had undergone cardiac surgery, resigned.
Management notified officials of this pause and resumed operations a month later.
But in September 2022 they stopped again. That hiatus continued until October 2023. During this time, three of the hospital’s four cardiac surgeons resigned and the last was fired.
During all this time, however, patients still arrived in need of care, but the lack of organization and staff created 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 Rocky Mountain ICU. in early 2023 with difficulty breathing and irregular heartbeat. it was soon discovered that he was showing signs of heart failure.
The report states that two different doctors recommended two different courses of treatment.
The patient quickly declined and went into cardiac arrest, but the ICU staff had no cardiac specialists on site to care for his fragile health and resorted to seeing a cardiologist via telehealth.
OIG officials wrote that the patient died despite the best efforts of intensive care unit staff, who were left to care for the man solely on the advice of a telehealth cardiologist.
The report stated that This situation illustrates how “unclear guidance” from management may have “put patients at risk for adverse clinical outcomes.”
An anonymous ICU doctor told investigators that the advice given by the virtual consultation specialist was “not helpful.”
Later that year, more resignations occurred and the assistant directors of anesthesiology, general surgery and behavioral health left the eastern Colorado hospital.
The second investigation concentrated the majority of cultural issues within the Colorado hospital on four roles: facility director, chief of staff, deputy chief of staff for inpatient operations, and associate chief of staff for education.
In an anonymous interview, one doctor told investigators that during a last-minute town hall meeting called in 2023, the center’s chief of staff and director began “just berating us for stepping out of the hierarchy…
‘…what was apparently a town meeting was simply us being questioned for going outside our chain of command.’
Investigators concluded that top officials created “widespread marginalization and a culture of fear” that led to the resignations.
An independent and anonymous psychologist employed at the hospital described distress among staff that had led to an “exodus” of qualified staff at all levels, which in turn harms care for veterans.
According to the report, staff did not dare carry out risky but necessary procedures, as they felt they could not express their opinions without fear of reprisals. Managers were said to have used reports of safety problems as “a way to assign blame”.
The 1.2 million-square-foot hospital was completed in 2019. Construction, which cost the Army Corps of Engineers $1.7 billion, began in 2014.
The OIG report said new leadership plans to address these concerns by holding “listening sessions” to foster a healthier hospital culture. The Denver Post reported.
Sunaina KumarThe executive director of the VA Rocky Mountain Network, which oversees veterans hospitals in Colorado, Oklahoma and Utah, thanked the OIG for its investigation in a public statement.
Asked for a response for comment for this story, VA representatives told DailyMail.com that Ms Kumar said: “These investigations will help ensure that veterans, employees and stakeholders have full confidence in the quality and integrity of the leadership and the care provided.”
There have been significant leadership changes in the organization over the past year and the report says interim leaders are addressing these issues.
On a larger scale, the OIG report recommended that the federal VHA increase oversight of its hospitals, including conducting leadership reviews, conducting exit interviews with employees and creating a feedback system for employees to share concerns.
Local VA leaders, like Ms. Kumar, appear to be on board with the change.
“The VA OIG released two reports that show we have work to do here and I am fully committed to rebuilding trust with the veterans we serve,” Ms. Kumar said.
Sunaina Kumar, executive director of the VA Rocky Mountain Network, thanked the OIG for its investigation
Even with increased attention paid to the national VA health care system in recent decades, national disparities still exist between veterans who use VA health care and those who opt for private providers.
Under this system, veterans can apply for health care benefits through the Department of Veterans Affairs’ Civilian Health and Medical Program.
It covers health care services and supplies for veterans at all VA medical centers, but typically does not cover services provided at outside medical clinics.
Veterans may also choose to use private insurers for their health care.
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 by The RAND Corporationa think tank that advises on U.S. public policy.
Additionally, veterans across the country struggle to get the care they need at VA hospitals. A 2021 survey of 8,670 military families found their top concern was accessing VA care.
Approximately 9.2 million veterans are enrolled in this health care system, about half of all living veterans.
Respondents said problems scheduling appointments, accessing appropriate care, and poor quality of care were the main barriers to getting the help they needed.
in a separate 2021 Mission List Survey It was found that there were not enough appointments available, whether for heart surgery or mental health services, for the 16.5 million veterans living in the United States in 2021.