Inspector: ‘Culture of fear’ at Colorado VA hospital affected staff, veteran care

DENVER (KDVR) — Two inspection reports released Monday on the VA Eastern Colorado Health Care System hospital in Aurora showed that leadership created a culture that negatively impacted staff but did not substantiate any veteran patient’s harm.

The report focused on the leaders at the VA hospital in Aurora after allegations surfaced that they had created an environment that undermined the culture of safety.

“The OIG found widespread disenfranchisement and a culture of fear contributed to poor organizational health and numerous clinical leader resignations,” the report stated.

A change in staffing also caused at least five surgical nurses to leave the VA hospital, stopping cardiothoracic surgeries in the surgical ICU without sufficient planning.

The leadership report specifically identified key senior leaders as the facility director, chief of staff, deputy chief of staff for inpatient operations and associate chief of staff for education. The VA Office of Inspector General looked at whether this group “created a culture of fear” and “failed to practice high reliability organization principles,” which are meant to ensure “evidence-based, exceptional care” for every patient in the VA system, according to the report.

The report also noted that as of October 2023, all executive leaders at the facility had completed “baseline supervisory” training on high-reliability organization principles. However, the report said more than 50 current and former employees told inspectors that key senior leaders did not incorporate those principles into their practices, to such a level that they failed to establish and support a psychologically safe environment.

OIG leaders met with the facility leaders on Aug. 31, 2023, to share concerns and discuss the loss of clinical leaders. Through interviews, correspondence and other investigative measures, the OIG found that key senior leaders had created an environment where many clinical and administrative leaders, in addition to frontline staff and those on service lines, “felt psychologically unsafe, deeply disrespected, and dismissed, and feared that speaking up or offering a difference of opinion would result in reprisal.”

The report also shared quotes from the facility director who was asked about actions taken to demonstrate psychological safety to staff. The facility director reportedly asked OIG staff to “show me who’s been fired. Show me who’s been retaliated against,” and said that they sought to engage staff through “rounding on units,” quarterly town halls and listening meetings, in addition to attending and presenting at medical staff meetings.

“I don’t know where the hysteria is coming from, but some people have really worked others up,” the facility director reportedly told OIG.

OIG also sent questionnaires to former leadership of the Aurora facility and received 20 responses from those employed during 2021-23.

All of them reported a “lack of trust and confidence in senior leaders was an important factor in their decision to leave facility employment.” Some reported poor or unsafe working conditions, and “most provided narrative responses that described the unsafe working condition as being psychologically unsafe,” like perceiving the facility director as “a bully” or as if they felt “bullied at times.” The report also quoted them saying “there was an overall fear and distrust when it came to the (executive leadership team),” as well as a “paranoid and fearful” culture and a “toxic environment.”

VA Rocky Mountain leadership respond

VA Rocky Mountain Network Director Sunaina Kumar-Giebel told FOX31 in a statement that the VA is committed to patient care and safety.

“Allegations of unsafe patient care or misconduct are taken seriously. As part of existing allegations against former VA Eastern Colorado Health Care System leadership and risks associated with patient care in the ICU, VA OIG conducted an inspection to determine the full and complete details of the allegations and their validity,” Kumar-Giebel 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.”

Because of these reports and findings, the OIG has seven recommendations for the Aurora facility, all of which appear to be concurred by the current administration.

The recommendations include two potential reviews of the organization by the undersecretary for health and one recommendation that the VA Eastern Colorado Health Care System director “actively seek and utilize” employee exit survey data to try and improve employee retention and address the facility’s challenges.

The last four are for the Veterans Integrated Service Network director, including a request for a review of the key leadership’s actions, evaluating of the clinical service leader vacancies, creation of a way for employees to provide periodic feedback on the culture and leaders’ practices and a human resources officer to ensure employee access to the most current version of the VA exit and transfer surveys.

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