Congressman Crow, Senators Bennet and Hickenlooper Urge VA Rocky Mountain Network’s Action to Address Patient Care Concerns

AURORA — Congressman Jason Crow (CO-06), Army veteran, and Colorado US Senators Michael Bennet (D-CO) and John Hickenlooper (D-CO), sent a letter to Veterans Affairs Rocky Mountain Network (VISN 19) leadership calling for immediate action in response to issues related to Colorado veteran patient care within the Veterans Affairs Eastern Colorado Health Care System (VA ECHCS) network and at Rocky Mountain Regional VA Medical Center. This comes on the heels of the Veterans Affairs Office of Inspector General’s (VA OIG) alarming reports that found multiple leadership failures at the Rocky Mountain VA (RMR VA) Medical Center, an extended pause in cardiothoracic (CT) surgeries resulting in the loss of all CT staff, a culture of fear created by key leaders at the facility, and a failure in oversight by VISN 19. 

In the letter, Congressman Crow and Colorado's Senators express concern regarding veteran patient care, ongoing quality issues within VA ECHCS, problems related to budget cuts and hiring freezes, call for immediate action to address the OIG recommendations, and call for active oversight of RMR VA by the Department of Veterans Affairs. They request their offices are kept apprised of solutions to protect the health and safety of our veterans and provide the quality care they deserve. 

Previously, Crow with Colorado bipartisan delegation leaders led a letter to VA Secretary Denis McDonough to address reports of mismanagement and toxic staff culture at ECHCS.  

“As problems persist within the ECHCS, we are increasingly concerned about the quality of care Colorado veterans receive, a lack of adherence to the required medical and employee procedures, and how recent leadership changes have impeded the system’s effectiveness…In light of these issues, we request answers to the following questions and a briefing with our offices in order to identify long-term solutions to improve veteran care in Colorado,” wrote Crow, Bennet, and Hickenlooper. 

“We share the goal of providing veterans across the country with timely, quality, and consistent health care. The continuous appointment delays and ongoing quality issues at ECHCS undermine this objective,” they continued. 

Congressman Crow continues conducting critical oversight of the state’s largest VA hospital located in Colorado’s 6th District. In December, Crow sent a letter to VA Under Secretary for Health Dr. Shereef Elnahal to address concerning reports of canceled prosthetics orders and staff morale issues. In March, Crow welcomed Under Secretary Elnahal to the RMVA for an oversight visit and VA employee town hall. 

A PDF of the letter can be found here, with text appearing below:  

Dear Mrs. Kumar-Giebel and Dr. Bray-Hall: 

We write to express our concern regarding veteran patient care within the Eastern Colorado Health Care System (ECHCS) and at the Rocky Mountain Regional Medical Center. In a report released in June, the Veterans Affairs Office of Inspector General (VA OIG) found a “lack of resident supervision, an ineffective teaching environment for residents, and patient harm,” in the Intensive Care Unit (ICU) at the Rocky Mountain VA.1 In addition to the VA OIG findings, there are reports of unidentified residues found on reusable surgical equipment, which has led to over 500 canceled surgeries at the Rocky Mountain VA.2 3 Further, our offices have received information from VA employees who highlight ongoing problems related to leadership turnover, budget cuts, and hiring freezes. As problems persist within the ECHCS, we are increasingly concerned about the quality of care Colorado veterans receive, a lack of adherence to the required medical and employee procedures, and how recent leadership changes have impeded the system’s effectiveness.

While we appreciate the VA OIG’s recent recommendations intended to address issues in the ECHCS between April 2022 and August 2023, it is paramount that you address more recent events at the Rocky Mountain VA.4 These concerns must be taken seriously and require active oversight by the Department of Veterans Affairs. In light of these issues, we request answers to the following questions and a briefing with our offices in order to identify long-term solutions to improve veteran care in Colorado: 

Patient Safety

1. Does the Rocky Mountain VA track occurrences of patient safety issues? If yes, please provide the number of safety issues that have occurred and how you’ve addressed them. If not, please explain why these issues are not monitored. 

Unidentified residue and resulting delayed care 

1. Does the Rocky Mountain VA follow the Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) to ensure consistency of sterilization practices? If the Rocky Mountain VA does not follow CDC guidelines, please provide the details of the process you follow and confirm adherence. 
2. When did the Rocky Mountain VA first become aware of the unidentified residue in its surgical units? When did the Rocky Mountain VA first begin canceling surgeries as a result of this residue? 
3. Has the Rocky Mountain VA conducted a full investigation into the cleanliness and sterilization of all medical equipment? 
4. How many days, weeks, or months are veterans’ surgeries delayed as a result of this investigation? 
5. How much advance notice have veterans received before their surgeries are canceled? 
6. Have these surgical pauses delayed any additional medical services within the Rocky Mountain VA Hospital? 
7. Where are veterans being referred for care in lieu of treatment at the Rocky Mountain VA? Is the VA reimbursing veterans for additional travel incurred to receive surgery at other hospitals? 
8. What continuing education requirements are there for sterile processing technicians within the Veterans Health Administration; and when is the last time your sterile processing curriculum and training were updated? 
9. Given recent instances of sterile processing issues in Georgia in 2021, Indiana in April 2024, and now Colorado in March 2024, will the Department of Veterans Affairs require sterile processing training and curriculum to be updated on an annual basis?

Staff shortages and organizational culture

1. How do ongoing staff shortages affect the Rocky Mountain VA’s ability to provide timely and quality health care to veterans, including mental and dental care? 
2. How many surgical and non-surgical divisions within the Rocky Mountain VA are currently understaffed?
3. What is your timeline to address these staffing shortages and is there a timeline to lift the hiring freeze? 
4. What is your timeline to replace interim directors in the organization with permanent positions?
5. Veterans across the ECHCS have reported waiting many months for their first face-to-face appointment with a VHA provider. What is the average wait time for a veteran to be seen by their provider upon requesting an appointment? Please provide information for the following visits: 
   1. 1st Dental
   2. 1st Mental Health
   3. 1st Primary Care Visit
   4. 1st Sleep Care
   5. 1st Social Work 
6. What is the staff size of a Physician Aligned Care Team (PACT) and how many patients do PACTs have?
7. What steps has the Rocky Mountain VA taken to address pervasive organizational "cultural" problems that disincentivize the ability to identify and resolve problems in procedures, staffing, and medical care?

We share the goal of providing veterans across the country with timely, quality, and consistent health care. The continuous appointment delays and ongoing quality issues at ECHCS undermine this objective. We look forward to receiving your response to these questions by August 10, 2024.