Colorado VA medical facility leaders created a ‘psychologically unsafe’ environment for employees

A pair of inspector general reports published Monday about toxic workplace environments, poor leadership and gaps in patient care at a Veterans Affairs Department medical facility in Colorado is the latest in a string of scandals affecting the agency’s workforce. 

The VA Office of the Inspector General substantiated allegations that senior leaders at the VA Eastern Colorado Health Care System in Aurora created an environment where many employees “felt psychologically unsafe, deeply disrespected and dismissed and feared that speaking up or offering a difference of opinion would result in reprisal.” 

In the second report, the OIG found that staff departures at the same location caused a pause in cardiothoracic surgery that lasted from September 2022 to October 2023. Facility officials did not inform higher-ups at the VA. 

“VA is committed to maintaining excellent patient care and prioritizing a culture of safety. Allegations of unsafe patient care or misconduct are taken seriously,” said Sunaina Kumar-Giebel, director of the VA Rocky Mountain Network, in a statement. “These investigations will help ensure veterans, employees and stakeholders have full confidence in the quality and integrity of the leaders and care delivery provided.” 

The OIG report regarding the Colorado facility’s workplace culture focused on four officials, including the facility director and chief of staff. According to the VA, the director and chief of staff were reassigned to temporary positions not related to health care while the investigations were taking place. And two other individuals resigned. 

The report found that the environment at this facility contributed to numerous clinical leader resignations. Nine such leaders resigned between 2022 and 2023. 

As a result, some senior leaders have been performing dual roles. For example, the deputy chief of staff for inpatient operations also has been serving as the acting chief of medicine from January 2023 until at least October of the same year. That position was originally vacated in September 2020. 

One staff member told investigators about an “ironic exchange” at a town hall with the facility director. 

“So when the director became very angry after learning that we had been going around the normal chain of command to ask for help and telling us that we were to stop doing that, one of the primary care doctors…told him…the reason we’re doing this is because we don’t have anyone to talk to. No one’s listening to us,” they said. “And [the facility director]...sort of stood over [the primary care doctor] and told [them] ‘you need to go through your supervisor and the right chain of command.’ At which point that primary care doctor reminded him that they haven’t had a chief of primary care in four years, and [the facility director] didn’t seem to know what to do with that.”  

Ultimately, more than 50 current and former employees told investigators that the leaders failed to follow VA’s leadership principles, including by not supporting a psychologically safe environment. 

Additionally, the second report concluded that changes leaders of the facility made to its intensive care unit took place without adequate planning or input. Consequently, ICU residents for approximately two months did not have overnight on-site supervision and were told to use a teleservice in which doctors and nurses offer ICU care via live audio and video. The OIG determined that facility leaders did not provide written procedures or policies on how to use such teleservice. 

The report did not find that these actions resulted in harm to patients but noted that they could have. 

Between the two reports, the OIG made 13 recommendations, including that the under secretary for Health review the Veterans Integrated Service Network leaders’ oversight of the system’s operations and use the review to standardize VISN leaders’ supervisory roles and responsibilities. Department officials concurred with each of the recommendations. 

Rep. Jason Crow, D-Colo., — who represents Aurora and who has previously raised concerns about staff morale at the VA facility with department officials — 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.” 

Just this year, the House Veterans’ Affairs Committee voted to subpoena the VA as part of an investigation into sexual harassment allegations at the top ranks of its harassment prevention office; the department suspended three police officers at the Atlanta VA Medical Center over similar allegations; and Veterans Affairs Secretary Denis McDonough apologized after the VA mistakenly approved $11 million in bonuses to executives.