Leaders at the VA Eastern Colorado Health Care System in Aurora Created an Environment That Undermined the Culture of Safety

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations that senior leaders failed to practice high reliability organization (HRO) principles and created a culture of fear at the VA Eastern Colorado Health Care System (facility) in Aurora. The OIG substantiated the allegations and found key senior leaders created an environment where a significant number of clinical and administrative leaders and frontline staff, from a multitude of service lines, felt psychologically unsafe, deeply disrespected, and dismissed, and feared that speaking up or offering a difference of opinion would result in reprisal. Further, the OIG substantiated that following the addition of two key senior leaders to the peer review committee (PRC) in 2023, the culture of the committee changed to an environment perceived by six members, as well as non-PRC service leaders and staff, to be psychologically unsafe and punitive. When learning of concerns, key senior leaders missed opportunities to understand concerns and make efforts to foster a psychologically safe environment. The OIG substantiated that mid-level leadership had been eroded and three key senior leaders held a monopoly of control. The OIG found leadership instability at the service level, with many clinical service and section-level resignations and extended vacancies. Further, numerous former leaders left facility employment citing that a psychologically unsafe work environment was a major factor in their decision to leave. Despite these losses, key senior leaders did not seek or utilize employee exit survey data to identify and address employee retention challenges. Turnover in VISN leadership positions and ineffective communication contributed to the VISN Director’s lack of awareness regarding the extent of the staffing and culture challenges at the facility. The OIG made two recommendations to the Under Secretary for Health, four recommendations to the VISN Director, and one recommendation to the Facility Director.