Johns Hopkins All Children’s Hospital (St Petersburg, Florida) – problems in the hospital’s heart surgery unit

Assignment: How would this problem have been avoided if Johns Hopkins quality assurance and patient safety protocols been followed?

“The Patient Safety and Healthcare Quality Masters program is a fully online, interdisciplinary degree offered by Johns Hopkins University. It is a first-of-its-kind collaboration between the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Johns Hopkins School of Nursing and the Armstrong Institute for Patient Safety and Quality. It combines coursework from JHU’s top ranked schools and the Armstrong Institute’s pioneering advances in patient safety-educating students in the transformative mechanisms and evidence-based protocols that reduce preventable patient harm and improve clinical outcomes.
Renowned, industry-shaping experts lead this exciting new program designed for working adults. The program focuses on: Measurement of safety and quality; Designing safer systems; Organizational and cultural change. ” (A)

“Patient Safety and Quality at Johns Hopkins Medicine.
Each day in a hospital, staff members undertake complicated tasks caring for patients. Johns Hopkins Medicine’s patient safety efforts aim to ensure that all of these steps work together to deliver high-quality, compassionate care to all patients across our health system.
Johns Hopkins Health System hospitals and services consistently receive awards and honors for patient safety and quality, including Top Performer on Key Quality Measures by the Joint Commission, Magnet designation for nursing, HomeCare Elite and Delmarva Foundation Excellence Awards. The Johns Hopkins Hospital has been ranked No. 1 in the nation by U.S. News & World Report for 22 years of the survey’s 25-year history, most recently in 2013.
Patient Safety and Quality Measures
This website shares data for the Johns Hopkins Health System. Here, you will find information about key safety issues and the patient’s experience of care, including:
Patient Experience – Based on survey results from previous patients, you can see how others rated their experience of care from a Johns Hopkins Medicine hospital or home health care provider.
Infection Prevention – These measures include the rate of CLABSIs, a bloodstream infection caused by a central line (large IV) that are considered preventable and hand hygiene, the percentage of medical staff members observed washing their hands or using hand sanitizer before and after caring for a patient.
Core Measures – These measures are national standards of care and treatment processes for common conditions. Core measure compliance shows how often a hospital follows each of these steps.
Surgical Volumes – Studies have shown a strong relationship exists between the number of times a hospital performs a specific surgical procedure and the outcomes for those patients. In 2016, we started sharing our hospitals’ surgical volumes for many common and high-risk procedures.
Quality of Care Ratings – The quality of patient care star rating is a summary of how well the Johns Hopkins Home Care Group and Potomac Home Health Care perform on nine quality measures such as ambulation.
Pediatrics – These measures include national standards of treatment for common conditions, infection prevention, pain management and emergency department wait times for Johns Hopkins’ pediatric divisions.
Hospital Readmissions – Patients are most vulnerable for readmission to a hospital immediately following discharge. This measure tracks how many Medicare patients with specific conditions were readmitted to the hospital within 30 days for any reason.
Our Commitment to Transparency
Patients and their loved ones deserve to be informed about the quality of their heath care. At Johns Hopkins Medicine, we are dedicated to sharing our performance and how we work to provide the best care with past, present and future patients. The Johns Hopkins Armstrong Institute for Patient Safety and Quality coordinates safety and quality improvement efforts and training across our health system.
We hope you will find this website a valuable resource and encourage you to ask your health care team if you have any questions or concerns. (B)

“Patient Trust, Confidence Built on Interprofessional Innovation
Medical errors and preventable patient infections and injuries together make up the third-leading cause of death in the United States, a startling statistic.
The Johns Hopkins School of Nursing understands that an increasing focus on patient safety and quality of care depends upon a healthcare workforce that knows the risks and the proper responses from patients’ arrival to their safe discharge.
The Helene Fuld Leadership Program for the Advancement of Patient Safety and Quality (The Fuld Fellows Program) emphasizes interprofessional education and training, simulation, and service-learning experiences involving nurses, medical students, pharmacists, and other health professionals whose collaboration is critical for reducing preventable harm to patients.
Nurses, as the primary contact with patients, play a key role in their safety. Hopkins Nursing, as part of an interprofessional team that includes the Armstrong Institute for Patient Safety & Quality and the Johns Hopkins Health Systems, works to prepare nurses ready to communicate, cooperate, innovate, and lead on issues of patient safety and quality of care.” (C)

“Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality
A roadmap for patient safety and quality improvement
This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.
An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.
A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.
Today, based on years of work by patient safety researchers-including many at Johns Hopkins-hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.

Top 10 Recommended Patient Safety Strategies
1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.
2. Bundles that include checklists to prevent central line-associated bloodstream infections
3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols
4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia
5. Hand hygiene
6. The do-not-use list for hazardous abbreviations
7. Multicomponent interventions to reduce pressure ulcers
8. Barrier precautions to prevent healthcare-associated infections
9. Use of real-time ultrasonography for central line placement
10. Interventions to improve prophylaxis for venous thromboembolisms…
Even with a list of sound strategies, creating a plan to implement all or even half of them may sound like a daunting task. The Armstrong Institute for Patient Safety and Quality has created a checklist to help you get started.
1. Identify priorities and assess readiness for change.
2. Establish engagement and accountability at all levels of the organization.
3. Communicate constantly (the good and the bad).
4. Measure, measure, measure… and then measure some more. (D)

“Johns Hopkins All Children’s Hospital provides expert pediatric care for infants, children and teens with some of the most challenging medical problems in our community and around the world.
Named a top 50 children’s hospital by U.S. News & World Report, we provide access to innovative treatments and therapies. Taking part in pediatric medical education and clinical research helps us to provide care in more than 50 specialties.
With more than half of our 259 beds devoted to intensive care level services, we are the regional pediatric referral center for Florida’s West Coast. Physicians and community hospitals count on us to care for critically ill patients and perform complex surgical procedures.
Parents count on us, too. Our philosophy of family-centered care means family members are an important part of our health care team. We include parents in making decisions and plans for their child’s care. We also include patients who are old enough to take part in these discussions.
To help us design our hospital that we opened in January 2010, we asked patients, parents and our staff to share ideas. The result was a spacious and bright hospital with individual rooms where parents can comfortably spend the night. With the latest technology and our commitment to family-centered care, our hospital provides an ideal environment for healing.” (E)

“Quality, Outcomes and Patient Safety at Johns Hopkins All Children’s
We are committed to treating you and your child with compassion and respect. We believe that you deserve honesty in our communication about the plan for your child’s care and we will demonstrate uncompromising integrity to earn your trust. We will be responsible for including each family as a part of our care team that is committed to safe and innovative care practices. Our goal is to inspire hope for you and your child through our focus on inquiry, collaboration, and team work.
Johns Hopkins All Children’s Hospital believes in Creating healthy tomorrows… for one child, for All Children. Our focus on Quality assures that we are continually improving our processes in an effort to achieve this vision. Using a team approach we tap into the know-how of our expert medical staff and employees to improve the quality and safety of the care we provide.
Our Quality Model provides the basis for understanding patient needs, measuring and using data, and achieving real improvement. Improving continuously is our goal. To do this we encourage each member of our team to find ways to do their work better and to make patient safety a priority. Together we are focused on pursuing perfection for All Children.
Quality Measures
There are many ways to look at and measure quality. Our data uses information from key areas to help families, healthcare providers, and others learn about our progress in pursuing perfection for All Children.” (F)

“Sandra Vázquez paced the heart unit at Johns Hopkins All Children’s Hospital.
Her 5-month-old son, Sebastián Vixtha, lay unconscious in his hospital crib, breathing faintly through a tube. Two surgeries to fix his heart had failed, even the one that was supposed to be straightforward.
Vázquez saw another mom in the room next door crying. Her baby was also in bad shape.
Down the hall, 4-month-old Leslie Lugo had developed a serious infection in the surgical incision that snaked down her chest. Her parents argued with the doctors. They didn’t believe the hospital room had been kept sterile.
By the end of the week, all three babies would die…
The internationally renowned Johns Hopkins had taken over the St. Petersburg hospital six years earlier and vowed to transform its heart surgery unit into one of the nation’s best.
Instead, the program got worse and worse until children were dying at a stunning rate, a Tampa Bay Times investigation has found.
Nearly one in 10 patients died last year. The mortality rate, suddenly the highest in Florida, had tripled since 2015…
Times reporters spent a year examining the All Children’s Heart Institute – a small, but important division of the larger hospital devoted to caring for children born with heart defects…
They discovered a program beset with problems that were whispered about in heart surgery circles but hidden from the public.
Among the findings:
All Children’s surgeons made serious mistakes, and their procedures went wrong in unusual ways. They lost needles in at least two infants’ chests. Sutures burst. Infections mounted. Patches designed to cover holes in tiny hearts failed.
Johns Hopkins’ handpicked administrators disregarded safety concerns the program’s staff had raised as early as 2015. It wasn’t until early 2017 that All Children’s stopped performing the most complex procedures. And it wasn’t until late that year that it pulled one of its main surgeons from the operating room.
Even after the hospital stopped the most complex procedures, children continued to suffer. A doctor told Cash Beni-King’s parents his operation would be easy. His mother and father imagined him growing up, playing football. Instead multiple surgeries failed, and he died.
In just a year and a half, at least 11 patients died after operations by the hospital’s two principal heart surgeons. The 2017 death rate was the highest any Florida pediatric heart program had seen in the last decade.
Parents were kept in the dark about the institute’s troubles, including some that affected their children’s care. Leslie Lugo’s family didn’t know she caught pneumonia in the hospital until they read her autopsy report. The parents of another child didn’t learn a surgical needle was left inside their baby until after she was sent home.
The Times presented its findings to hospital leaders in a series of memos early this month. They declined interview requests and did not make the institute’s doctors available to comment.
In a statement, All Children’s did not dispute the Times’ reporting. The hospital said it halted all pediatric heart surgeries in October and is conducting a review of the program.
“Johns Hopkins All Children’s Hospital is defined by our commitment to patient safety and providing the highest quality care possible to the children and families we serve,” the hospital wrote. “An important part of that commitment is a willingness to learn.” (G)


The top three leaders of Johns Hopkins All Children’s Hospital in Florida resigned Tuesday following a Tampa Bay Times investigation that revealed increasing mortality rates among heart surgery patients.
The resignations from the 259-bed teaching hospital in St. Petersburg included CEO Jonathan Ellen, M.D., and Vice President Jackie Crain, as well as Jeffrey Jacobs, M.D., who is the heart institute’s deputy director, the Tampa Bay Times reported. Paul Colombani, M.D., stepped down as chairman of the department of surgery but will continue working in a clinical capacity, a statement from the health system said.
“Losing a child is something no family should have to endure, and we are committed to learning everything we can about what happened at the Heart Institute, including a top-to-bottom evaluation of its leadership and key processes,” a statement from Johns Hopkins read. “The events described in recent news reports are unacceptable.”
Johns Hopkins, which owns and operates the hospital, said it would install Kevin Sowers, who is president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, to lead the hospital in a temporary capacity while a plan for interim leadership is put into place.
George Jallo, M.D., who is medical director of the Institute for Brain Protection Sciences and chief of pediatric neurosurgery, will serve as interim vice dean and physician-in-chief, and Paul Danielson, M.D., who is chief of the Division of Pediatric Surgery at Johns Hopkins All Children’s Hospital, will serve as interim chair of the surgery department.
Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program and said it would share its lessons from the review to help hospitals around the country avoid the same mistakes.
The moves come following the Tampa Bay Times investigation that highlighted a growing number of heart surgery deaths at the hospital amid warnings about safety from staffers that went unheeded. (H)

“Three additional senior administrators have left Johns Hopkins All Children’s Hospital in the wake of a Tampa Bay Times investigation into high mortality rates at the hospital’s Heart Institute, the hospital announced Wednesday.
A total of six senior officials have left since the Times report, including the hospital’s CEO, three vice presidents and two surgeons who held leadership roles at the Heart Institute. A seventh official stepped down as chairman of the surgery department but remained employed at the hospital as a doctor.
The resignations announced Wednesday included vice presidents Dr. Brigitta Mueller, the hospital’s chief patient safety officer, and Sylvia Ameen, who oversaw culture and employee engagement and served as the hospital’s chief spokeswoman.
The hospital also said Dr. Gerhard Ziemer, who started as the Heart Institute’s new director and chief of cardiovascular surgery in October, would leave the hospital. The hospital never publicly announced Ziemer had been hired, and he had not yet obtained his Florida medical license when the Times investigation was published at the end of November. At that point, the hospital said the Heart Institute had already stopped performing surgeries.
“While Dr. Ziemer is not responsible for the current state of the program, we agreed that a fresh start was needed to ensure success for the program,” Johns Hopkins Health System President Kevin Sowers said in a letter to the hospital’s staff.” ..
In his letter to the staff, Sowers said that several hospital executives had been tasked with leading “critically important work around advancing our culture of safety.”
“As we work to rebuild the trust of our community, we must also work to fully embrace and support a culture where we are each empowered and encouraged to speak up and speak out if we see or hear something that concerns us,” he wrote. “This commitment applies to clinical concerns as well as inappropriate workplace behavior.”
Sowers also announced that Johns Hopkins had hired external experts to develop a plan to restart heart surgeries at All Children’s.
That is a separate effort from an external review of the problems in the Heart Institute, which Johns Hopkins announced its board had commissioned last month, spokeswoman Kim Hoppe said…
Johns Hopkins is one of the most prestigious brands in medicine and is internationally renowned for developing innovative patient safety protocols that are used at hospitals across the world. But last weekend, the Times published a story detailing a series of safety problems at hospitals across its network. In response, the health system pledged to “do better.” (I)

“The Johns Hopkins Medicine Board of Trustees has appointed a former federal prosecutor to lead its investigation into the Johns Hopkins All Children’s Hospital’s heart surgery unit, the health system announced late Tuesday.
F. Joseph Warin, of the global law firm Gibson Dunn, and his team will review the high mortality rates and other problems at the hospital’s Heart Institute and report back to a special committee of the board of trustees by May, the health system said.
Once the review is complete, the health system said it would also name an independent monitor at All Children’s to “make sure that the hospital is being held accountable for taking corrective action where necessary.”
The announcement was accompanied by a video of Johns Hopkins Health System president Kevin Sowers, who acknowledged for the first time that the hospital had been warned about problems by frontline workers.
“I know personally that many of you courageously spoke out when you had concerns but were ignored or turned away,” he said. “That behavior is unacceptable and will not be tolerated going forward.”
Sowers, who is also interim president at All Children’s, said he hoped to meet with the families of patients affected by problems in the Heart Institute in the coming days to share his “profound sadness for the failures of care they experienced.” (J)

“The external review was prompted by multiple reports by the Tampa Bay Times about problems at the center which could have contributed to its mortality rate tripling between 2015 and 2017…
Health News Florida’s Stephanie Colombini talked about what could come next with Kathleen McGrory, one of the lead reporters.
One of the big problems you uncovered in your reporting was the lack of available data about mortality rates at a lot of these heart surgery programs…
Officials have either refused to release it or they only release four-year averages, which could mislead families about the current state of the program they’re choosing.
How is the state looking at making these programs more transparent?
There were some problems at another pediatric heart surgery program in 2015 in Palm Beach County (St. Mary’s Medical Center), and after those problems surfaced, the legislature put together a panel (Pediatric Cardiology Technical Advisory Panel) tasked with looking at transparency and ways we could, as a state, make these programs better and more accountable.
That panel is in the middle of doing its work right now and in fact has come close to finalizing some recommendations.
The panel would like all of these heart surgery programs to be reporting their one-year data (on mortality rates) rather than their four-year data because that four-year data can sometimes hide serious problems…
So the state is looking into making heart surgery programs more accountable, but is anyone calling for change when it comes to the government’s role in this?
You reported that multiple times state and federal regulators were alerted to problems at All Children’s and yet little, to no action was taken.
We saw U.S. Reps. Kathy Castor and Charlie Crist put some really tough questions to federal regulators asking what they had investigated and when. We haven’t heard back yet on that front but we know it’s something they’ll be looking into.
The state told us that they did the best they could do with the information that they had, same thing with the federal government.
But ACHA has a new chief (Mary Mayhew). We haven’t gotten a chance to connect with her yet and see what her thoughts are on this, but we certainly will do that in the new year. (K)

“State and federal inspectors descended on Johns Hopkins All Children’s Hospital this week, following sharp calls for an investigation into problems in the hospital’s heart surgery unit, the Tampa Bay Times has learned.
The scope of the inspection is unclear. But hospital regulators had been criticized in recent weeks for their lax response to early signs of an increase in mortality at the hospital’s Heart Institute.
A Florida Agency for Health Care Administration spokeswoman said her agency had been at the facility.
A spokeswoman for the hospital confirmed federal inspectors had been there, too.
“We appreciate the oversight role that our regulators play and we will, as always, be fully cooperative and collaborative as they conduct any reviews necessary,” a statement from the hospital said.
A spokeswoman for the federal Centers for Medicare and Medicaid Services declined to comment beyond saying the matter remained “an ongoing review.”
In November, the Times reported that the mortality rate for heart surgery patients at All Children’s tripled from 2015 to 2017 to become the highest rate in Florida. The increase occurred after staff members warned the hospital’s leaders about problems with two heart surgeons, the Times found.
State and federal regulators knew the institute was having problems months earlier. In April, the hospital’s CEO told the Times that the institute had “challenges” that led to an uptick in mortality, and acknowledged the hospital had left surgical needles inside two children.
In May, state regulators cited the hospital for not properly reporting two medical mistakes, which is required by state law. Days later, a spokeswoman for the federal agency told the Times that it would perform its own investigation.
But state regulators didn’t fine the hospital, and overlooked several subsequent warnings that its surgical results had been poor.
And federal inspectors later changed course and decided not to undertake a comprehensive review of the heart surgery program, the Times reported last month. One reason was that state inspectors hadn’t found any violations of federal rules, a spokeswoman said. Another was that a nonprofit hospital accreditor was due to perform a scheduled review.” (L)


Two Omaha surgeons filed a lawsuit Friday against Children’s Hospital & Medical Center, alleging that they were wrongfully suspended and forced to resign privileges there after they raised patient safety concerns.
In the suit, Dr. Jason Miller and Dr. Mark Puccioni say that the hospital suspended their privileges to practice at the Omaha facility after they raised concerns about the death of a 7-month-old during an operation. That operation was performed this fall by another surgeon, Dr. Adam Conley, the suit says.
In their communications, according to the suit filed in Douglas County District Court, the two also questioned Conley’s “skill and ability.”
In addition to the hospital, the lawsuit names as defendants Conley, as well as Dr. Richard Azizkhan, who took over as Children’s president and CEO in October 2015.
Children’s officials said in a statement that the hospital does not comment on pending litigation “other than to say we strongly disagree with these allegations…
Children’s has faced other issues in recent months.
In late November, a former pharmacy director at the hospital was accused of funneling more than $4.4 million from the organization into her personal account over six years. She was terminated in June and faces a hearing regarding possible disciplinary action later this month.
About three weeks ago, the Nebraska Medical Association sent a letter to the board of Children’s Hospital expressing concerns about “patient care, safety and quality” at the Omaha hospital, in addition to the loss of longtime physicians.
In the Dec. 11 letter, the president of the group, Dr. Britt Thedinger, wrote, “We as physicians are concerned about the summary suspensions, terminations and resignations of long-time outstanding physician colleagues.” The letter also expressed concern that children were being transferred to outside institutions because of “complications” and inadequate staffing at the Omaha hospital.
Thedinger said the organization did not intend for the letter to become public. The intent, he said, was to bring issues that had been raised by members to the hospital board and administration.” (M)

“The New Jersey Department of Health is investigating four Acinetobacter baumannii cases in the neonatal intensive care unit (NICU) of University Hospital in Newark, authorities announced Thursday evening.
DOH officials stated:
“The department first became aware of this bacterial infection on Oct. 1 and two department teams have been closely monitoring the situation. Those department teams, which have been at the facility last week and this week, have been ensuring that infection control protocols are followed and are tracking cases of the infection. The department’s inspection revealed major infection control deficiencies.”
According to the DOH, a premature baby with the bacteria who had been cared for at University Hospital was transferred to another facility and passed away toward the end of September, prior to the department’s notification of problems in the NICU.
“Due to the other compounding medical conditions, the exact cause of death is still being investigated,” DOH officials said.
The department has ordered a Directed Plan of Correction that requires University Hospital to employ a full-time Certified Infection Control Practitioner consultant, who will report to the DOH on immediate actions taken in the coming days.
DOH officials said they are also exploring further actions the agency may need to take in the coming days to “ensure patient safety.” (N)

“Four New Jersey pediatric care facilities and one hospital are now under the state’s microscope after nine children died and 26 people were sickened by a deadly virus over the past month.
A Department of Health team of infection control experts and epidemiologists will visit University Hospital in Newark and four pediatric long-term care facilities in November to conduct training and assessments of infection control procedures, Commissioner Dr. Shereef Elnahal has announced.
The team of experts will visit University Hospital, the Wanaque Center for Nursing & Rehabilitation in Haskell, Voorhees Pediatric Facility in Voorhees and Children’s Specialized Hospital in Toms River and Mountainside. The department reached out to the facilities last week to schedule visits in November.
The decision comes after nine children at a Wanaque facility have died since an outbreak of the adenovirus was declared there. Victims became sick between Sept. 26 and Oct. 22. Authorities confirmed that the virus killed eight of the nine kids.
Twenty-six kids and a staff member, who has since recovered, have become ill as part of the outbreak, state health officials said. Laboratory tests confirmed the 26th case. (O)

“Two decades ago, the Institute of Medicine shook the medical profession with its “To Err is Human” report which said nearly 100,000 people a year lost their lives to preventable medical errors…
During the 7th Annual World Patient Safety, Science & Technology Summit over the weekend, the Patient Safety Movement Foundation released a new tool on its website to help with the training.
The patient safety curriculum is one of 17 Actionable Patient Safety Solutions (APSS) made available to organizations for free to help train health professionals in systems science so they can help find ways to reduce preventable patient deaths, officials said.
“The goal is to get every health professional to think in a system way,” said Steven Scheinman, M.D., the president and dean of Geisinger Commonwealth School of Medicine. He led a Patient Safety Movement working group which included experts from Geisinger, San Diego State, University of Pittsburgh Medical Center, Johns Hopkins Health, and MedStar Georgetown to develop the curriculum over an 18-month period.
The Patient Safety Movement was founded in 2013 to help reduce preventable deaths in healthcare and in 2015 set a goal of zero preventable deaths by 2020. More than 90,000 patients who might have died as a result of medical errors were saved in 2018 due to efforts made by more than 4,700 hospitals that committed to patient safety efforts, according to figures released by the foundation. In all, a total of 273,077 lives have been saved since the first summit, officials said.
The newly released safety curriculum can be adapted to any healthcare profession including medicine, nursing, pharmacy, and behavioral health and can be used for student training, as well as training for experienced professionals.
“We want to train every health professional to take ownership of the patient’s safety and experience so they understand safe communication and know when they are telling another person about the patient or handing them over or referring them over, how to make sure they get all the critical information there,” Scheinman said…
“The airline industry solved safety by creating the right systems,” Scheinman said. “Medical errors are very widespread. But they usually aren’t a doctor making a mistake. They can be. But they’re more often the system failed to pick something up or allowed something bad to happen.”
And with this training, he said, those medical professionals might be that much more likely to help figure out a new solution to make sure something bad doesn’t happen again.” (P)

“.. experience showcases the promise of a much-touted but little understood collaboration in health care: alliances between community hospitals and some of the nation’s biggest and most respected institutions.
For prospective patients, it can be hard to assess what these relationships actually mean – and whether they matter.
Leah Binder, president and chief executive of the Leapfrog Group, a Washington-based patient safety organization that grades hospitals based on data involving medical errors and best practices, cautions that affiliation with a famous name is not a guarantee of quality.
“Brand names don’t always signify the highest quality of care,” she said. “And hospitals are really complicated places.”..
To expand their reach, flagship hospitals including Mayo, the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed affiliation agreements with smaller hospitals around the country. These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated. For community hospitals, a primary goal of the brand-name affiliation is stemming the loss of patients to local competitors…
In some cases, large hospital systems opt for a different approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in the Washington, D.C., area, along with All Children’s Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All Children’s Hospital in 2016…
Although affiliation agreements differ, many involve payment of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as did executives at several affiliates. Contracts with Mayo must be renewed annually, while some with MD Anderson exceed five years…
“It is not the Mayo Clinic,” said Dr. David Hayes, medical director of the Mayo Clinic Care Network, which was launched in 2011. “It is a Mayo clinic affiliate.”
Of the 250 U.S. hospitals or health systems that have expressed serious interest in joining Mayo’s network, 34 have become members.
For patients considering a hospital that has such an affiliation, Binder advises checking ratings from a variety of sources, among them Leapfrog, Medicare and Consumer Reports, and not just relying on reputation.
“In theory, it can be very helpful,” Binder said of such alliances. “The problem is that theory and reality don’t always come together in health care.”
Case in point: Hopkins’ All Children’s has been besieged by recent reports of catastrophic surgical injuries and errors and a spike in deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief executive has apologized, more than a half-dozen top executives resigned and Hopkins recently hired a former federal prosecutor to conduct a review of what went wrong.
“For me and my family, I always look at the data,” Binder said. “Nothing else matters if you’re not taken care of in a hospital, or you have the best surgeon in the world and die from an infection.” ” (Q)



(A) https://applied-learning.jhsph.edu/masters-in-patient-safety?utm_source=bing&utm_medium=cpc&utm_term=%2Bhopkins+%2Bpatient+%2Bsafety&utm_campaign=RWC_JHUBSPH_MPSH_Search-PPC_Paid+Search_Bing_NonBrnd_Broad_Regional_Program-Related_NULL_Secondary&utm_content=MPSH%7Chopkins+patient+safety%7CBMM&uadgroup=MPSH%7Chopkins+patient+safety%7CBMM&uAdCampaign=RWC_JHUBSPH_MPSH_Search-PPC_Paid+Search_Bing_NonBrnd_Broad_Regional_Program-Related_NULL_Secondary&msclkid=899417c1ef841b340f434bffe8588404&gclid=CODg-puY8N8CFQndswodxncPJA&gclsrc=ds
(B) https://www.hopkinsmedicine.org/patient_safety/index.html
(C) https://nursing.jhu.edu/excellence/quality-safety/index.html
(D) https://armstronginstitute.blogs.hopkinsmedicine.org/2013/03/25/a-roadmap-for-patient-safety-and-quality-improvement/
(E) https://www.hopkinsallchildrens.org/About-Us
(F) https://www.hopkinsallchildrens.org/about-us/patient-safety
(G) Johns Hopkins promised to elevate All Children’s Heart Institute, by KATHLEEN McGRORY and NEIL BEDI, http://www.tampabay.com/projects/2018/investigations/heartbroken/all-childrens-heart-institute/
(H) Top officials at Johns Hopkins All Children’s Hospital resign following reports of heart surgery deaths, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/top-officials-at-johns-hopkins-all-children-s-hospital-resign
(I) Three more All Children’s officials resign following Times investigation, by By Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/02/three-more-all-childrens-officials-resign-following-times-investigation/
(J) Johns Hopkins hires former prosecutor to investigate All Children’s Heart Institute,by Kathleen McGrory and Neil Bedi , https://www.tampabay.com/investigations/2019/01/09/johns-hopkins-hires-former-prosecutor-to-investigate-all-childrens-heart-institute/
(K) Problems At All Children’s Hospital Could Lead To More Transparency Rules, by STEPHANIE COLOMBINI, http://wusfnews.wusf.usf.edu/post/problems-all-childrens-hospital-could-lead-more-transparency-rules
(L) State and federal inspectors visit All Children’s after reports on heart surgery deaths, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/11/state-and-federal-inspectors-visit-all-childrens-after-reports-on-heart-surgery-deaths/
(M) Doctors sue Children’s, alleging wrongful termination after raising concerns about child’s death, by Julie Anderson, https://www.omaha.com/livewellnebraska/health/doctors-sue-children-s-alleging-wrongful-termination-after-raising-concerns/article_185712cd-7156-5c9f-9ed3-52dafec9f0c4.html
(N) Bacteria In Newark Hospital NICU; Baby’s Death Being Probed: DOH, by Eric Kiefer, https://patch.com/new-jersey/newarknj/bacteria-newark-hospital-nicu-babys-death-being-probed-doh
(O) 5 NJ Facilities Under Microscope After Deadly Virus Outbreak by Tom Davis, https://patch.com/new-jersey/pointpleasant/5-nj-facilities-under-microscope-after-deadly-virus-outbreak
(P) Want health professionals to help reduce medical errors? Patient Safety Movement releases new curriculum, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/new-patient-safety-curriculum-released-at-patient-safety-movement-summit
(Q) Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles, by Sandra G. Boodman, https://khn.org/news/community-hospitals-link-arms-with-prestigious-facilities-to-raise-their-profiles/

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Jonathan M. Metsch, Dr.P.H.
jonathanmetsch@optonline.net

Log on to the AUPHA Network: http://network.aupha.org
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2. Johns Hopkins All Children’s has 3 weeks to correct safety lapses or lose Medicare funding

The agency placed the hospital in a rare status called “immediate jeopardy,” which federal guidelines describe as “a crisis situation.”..


“The federal government said a recent inspection of Johns Hopkins All Children’s Hospital found serious problems and threatened to cut off the institution’s public funding unless the issues are addressed in a matter of weeks.
The hospital was cited for not meeting federal rules on infection control, quality improvement, how it hires and manages doctors, and its leadership structure, according to a letter the Centers for Medicare and Medicaid Services sent the hospital Thursday.
The inspectors’ full report was not available Friday. But the letter says the findings were severe enough to constitute “an immediate or serious threat to patient health and safety.”..
Federal regulators do not directly control whether hospitals are allowed to operate. But they can cut hospitals off from public funds – a potentially devastating situation that could result in closure. Most hospitals are able to correct deficiencies and escape immediate jeopardy status before losing the money.
All Children’s has until Feb. 10 to provide a written plan to address the inspectors’ findings. If it does not correct the problems by Feb. 23, the government will stop allowing the hospital to bill it for new patients.
All Children’s spokeswoman Kim Hoppe said the hospital took the findings “seriously” and did not plan to appeal…
U.S. Rep. Kathy Castor, one of the lawmakers who called for an investigation, said she hoped to see “greater accountability for a hospital that used to be renowned for high quality care.”
“Johns Hopkins and state regulators allowed the quality of care to deteriorate and children died and were injured unnecessarily,” she said. “Our community deserves and demands so much better.”” (A)

  • Federal officials threaten All Children’s funding, citing problems, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/02/01/federal-officials-threaten-all-childrens-funding-citing-problems/




3. “An internal review by Johns Hopkins All Children’s Hospital has found more than a dozen incidents in which children in the hospital’s heart unit were harmed by the care they received.”

The cases should have been immediately reported to state officials, the hospital’s interim president told employees during private town halls this week. None were reported until recently.

The hospital’s former leaders also didn’t properly notify the board of trustees about safety concerns in the heart surgery department. That led to the federal government’s recent declaration that All Children’s had left patients in danger, the interim president said.

“Leadership knew there were quality and safety issues and did not elevate it in appropriate ways to the board,” said Kevin Sowers, who is president of the Johns Hopkins Health System and has also been the interim president at All Children’s since December.

Later, Sowers said that Johns Hopkins had “let this organization down.”

“Some of the people we put here did not act in the best interest of the children we were caring for or this organization,” he said…

Sowers described a series of lapses by the hospital’s former leaders — “people that we trusted,” he said — that hid the Heart Institute’s problems from the internal and external oversight designed to keep patients safe…

He said the hospital’s prior leadership team was aware of the Heart Institute’s problems. But when it filed a required quality improvement plan with the board, “there was absolutely nothing in the plan about the heart center,” he said…

In addition to discussing the governance issues, Sowers told employees the hospital had been cited by the state for not properly reporting the 13 cases in which patients had been harmed by medical care.

Under Florida law, the hospital should have reported those incidents within 15 days of them occurring.” (A)

“Time is just about up for Johns Hopkins All Children’s Hospital to submit its corrective plan to the feds.

The deadline is Sunday for the hospital to provide a written plan to fix serious problems that posed an “immediate or serious threat to patient health and safety” and were uncovered during a recent government inspection.

Several medical errors were found during the January inspection — including quality and infection control issues, plus staff management — but no fines were imposed.

The federal government threatened to cut funding if the hospital did not act…

A spokesperson said the hospital will meet the deadline.

“We take these findings seriously and are continuing to work in close coordination and consultation with both AHCA and CMS to immediately address their concerns,” Kim Hoppe said. “We will submit our corrective action plan by their deadline in areas including governance, physician credentialing, quality improvement planning and infection control.

“The safety of our patients is our top priority. We are confident in the work we are doing to ensure that our hospital continues to meet the highest standards of care.” (B)

“St. Petersburg, Fla.-based Johns Hopkins All Children’s Hospital submitted a corrective action plan after a Tampa Bay Times investigation found safety lapses in the hospital’s heart surgery program, CBS-affiliate TV station WTSP reports.

The hospital’s plan was turned in Feb. 10, just before the deadline. The corrective action includes governance shake-ups, new physician credentialing measures and changes to quality improvement planning and infection control.

In January, the Johns Hopkins Medicine Board of Trustees appointed a former federal prosecutor to lead its investigation into patient safety issues at the hospital.

Several patient safety issues, including quality and infection control problems, were found during a January visit by state and federal inspectors.”  (C)

“The corrective action includes governance shake-ups, new physician credentialing measures and alterations to quality improvement planning and infection control.

“The safety of our patients is our top priority,” the spokesperson said. “We are confident in the work we are doing to ensure that our hospital continues to meet the highest standards of care.” (D)

“The chairwoman of a powerful Florida Senate committee has filed a bill to dramatically increase oversight of children’s heart surgery programs.

The bill is designed to prevent problems like those at Johns Hopkins All Children’s Hospital. The St. Petersburg hospital experienced a sharp rise in heart surgery deaths that came to the attention of the public and regulators as the result of a Tampa Bay Times investigation published three months ago.

Florida Senate Health Policy Chairwoman Gayle Harrell, R-Stuart, said she filed the proposal in response to the issues at All Children’s and at St. Mary’s Medical Center in West Palm Beach, which stopped performing children’s heart surgeries in 2015 after CNN reported on the program’s high death rate.

She said the bill’s changes could have caught some of the issues sooner.

“These are the most fragile of children,” she said. “We want to make sure that we have standards in place and our cardiac centers are doing all they can to make sure children get the very best care.”

The bill, SB 1126, would let teams of pediatric heart doctors make unannounced visits to struggling programs. They would be able to review death records, inspect facilities and interview support staff and administrators.

After each site visit, the team would submit a report to the state’s Pediatric Cardiology Technical Advisory Panel, which would then recommend corrective action…

“We need to do things a little differently and make sure that there is the review of the standards that are expected to be met,” Harrell said…

Harrell’s proposal would let the panel recommend physician experts to visit existing programs and examine information that is not typically made available, including death records dating back one year.

The panel would also be able to make advisory recommendations on hospitals looking to open new pediatric heart surgery programs…

Separately from the new legislation, the panel is working a series of new rules for Florida heart surgery programs. Proposals under consideration include publishing far more detailed data online about heart surgery programs’ mortality rates. The new standards would need to be approved by the Agency for Health Care Administration.” (E)

“”Today Johns Hopkins All Children’s received word from the CMS that they have accepted our Plan of Correction and through an on-site survey have validated that all deficiencies related to the finding of immediate jeopardy have been addressed,” the hospital said in an emailed statement.

The problems were discovered after a review from the Department of Health & Human Services Centers for Medicare & Medicaid Services. Johns Hopkins All Children’s Hospital was notified that its participation in Medicare would terminate on Feb. 23 unless the hospital could meet substantive corrections to remove the conditions found.

Specifically, the facility did not meet the following conditions of participation, according to a CMS letter:

Governing body

Quality assurance performance improvement

Medical staff

Infection control

The finding from the CMS has now been removed, the hospital said in an emailed statement.

“This is good news but it is by no means the end of this important process. We take the issues raised by our regulators very seriously and will continue to collaborate closely with them as we implement our plan,” the hospital wrote. “We must be vigilant and diligent every day and, most importantly, we cannot forget what happened here and what we have learned.” “ (F)

“Choosing to have surgery at a facility affiliated with a highly rated U.S. hospital doesn’t guarantee the same quality experience, a new study in JAMA Surgery finds.

In an analysis of hospitals affiliated with U.S. News & World Report Honor Roll hospitals, surgical outcomes varied widely both within and across networks.

Moreover, Honor Roll hospitals didn’t always outperform network affiliates. While they had lower failure to rescue rates (13.3% versus 15.1%), their complication rates were actually higher (22.1% vs 18%).

Ben Harder, chief of health analysis at U.S. News, noted on Twitter that the study’s findings were not surprising. “That variation is why we evaluate discrete hospitals, not hospital system brands,” he said.” (G)

“A February follow-up inspection of Johns Hopkins All Children’s Hospital found the hospital was still out of compliance with federal rules, officials said this week.

Federal regulators cited problems with the hospital’s governance, quality assurance and infection control, and gave it a new deadline of mid-April to resolve the issues.

In a letter to Johns Hopkins Health System President Kevin Sowers Thursday, the Centers for Medicare and Medicaid Services said it would withhold public funding if the hospital missed the deadline.

It was the second letter the federal government has sent threatening to withhold funding. On Jan. 31, All Children’s was placed at risk of losing federal money because of problems with its governing board that put patients in “immediate jeopardy” of harm. Those specific problems have been addressed, federal regulators said.” (H)

“It should not take the deaths of young heart patients to spur action and better oversight of Florida’s cardiac programs. But the rising mortality rate at the Johns Hopkins All Children’s Hospital Pediatric Heart Institute revealed major gaps in how the state monitors quality of care and responds to problems. State lawmakers are right to consider legislation that would tighten oversight and better protect these fragile young patients…

Sen. Gayle Harrell, R-Stuart, has filed a bill that would allow teams of pediatric heart doctors to make unannounced visits to struggling programs at the Agency for Health Care Administration’s request to review patient records, inspect facilities and interview frontline and administrative staff. On-site inspections by experts in the field are an important part of ensuring quality care and rectifying problems before they escalate. Lawmakers should consider making such inspections annual to identify potential problems earlier.

Given the recent tragedies at All Children’s, where kids died following common heart surgeries, lawmakers should have increase oversight and transparency at Florida’s pediatric heart programs. No parent of a sick child should find out after the fact that a hospital they trusted made mistakes and failed to report them, and that the state failed to intervene. That’s what happened at All Children’s, and that’s what stronger oversight authority can prevent from happening again.” (I)

“The CMS now requires surveyors to complete a template when documenting instances of immediate jeopardy in an effort to better identify and resolve harm against patients at facilities.

In a blog post on Tuesday, CMS Administrator Seema Verma announced revisions to the guidance surveyors use to spot immediate jeopardy, requiring them to fill out a three-question template that describes the incident. The template is then shared with the facility so they have the information necessary to resolve the issue immediately.

Verma said the changes come from recent media attention surrounding harm at facilities. “Despite stringent safeguards, alarming stories continue to be reported about people, including some of our most vulnerable individuals, who have experienced harm in healthcare settings that is devastating to these patients and their families.”..

In recent months, an employee at a nursing home in Phoenix made national headlines after he was accused of raping a patient in a vegetative state. The facility announced it is closing. And just last month, immediate jeopardy was placed on Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, for deficiencies. Late last year, the Tampa Bay Times reported on the hospital’s above-average death rates for pediatric heart surgeries.” (J)

(A)       All Children’s says 13 heart surgery patients were hurt by care, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/02/09/all-childrens-says-13-heart-surgery-patients-were-hurt-by-care/

(B)       Deadline is today for All Children’s to provide plan to fix ‘serious’ safety issues, by Andrew Krietz, https://www.wtsp.com/article/news/local/pinellascounty/deadline-is-today-for-all-childrens-to-provide-plan-to-fix-serious-safety-issues/67-0a5e912d-f31b-44ec-93dd-4a89a268c5f1

(C)       Johns Hopkins All Children’s submits corrective plan to CMS amid safety lapse probe, by Megan Knowles, https://www.beckershospitalreview.com/quality/johns-hopkins-all-children-s-submits-corrective-plan-to-cms-amid-safety-lapse-probe.html

(D)       All Children’s Hospital hatches plan to fix its problems, by Sarah Rosario, https://www.wtsp.com/article/news/health/all-childrens-hospital-hatches-plan-to-fix-its-problems/67-90ee8f7b-2c9d-442c-9779-1a6a383a8632

(E)       After All Children’s deaths, proposal aims to catch heart surgery problems, by Kathleen McGrory, Neil Bedi and Elizabeth Koh, https://www.tampabay.com/investigations/2019/02/19/after-all-childrens-deaths-proposal-aims-to-catch-heart-surgery-problems/

(F)       Feds accept Johns Hopkins All Children’s Hospital plan to correct conditions putting patients in jeopardy, by Veronica Brezina-Smith, https://www.bizjournals.com/tampabay/news/2019/02/22/feds-accept-johns-hopkins-all-childrens-hospital.html a.fn.andSelf

(G) Quality varies wildly among affiliates linked with US News top hospitals, JAMA study finds, by Meg Bryant, https://www.healthcaredive.com/news/quality-varies-wildly-among-affiliates-linked-with-us-news-top-hospitals-j/550472/

(H) Federal inspectors find unresolved problems at All Children’s, by Bedi and Kathleen McGrory, https://www.tampabay.com/investigations/2019/03/08/federal-inspectors-find-unresolved-problems-at-all-childrens/

(I) Editorial: More eyes on pediatric heart programs, https://www.tampabay.com/opinion/editorials/editorial-more-eyes-on-pediatric-heart-programs-20190308/

(J) CMS creates tool for surveyors to spot immediate jeopardy, by MARIA CASTELLUCCI,   https://www.modernhealthcare.com/safety/cms-creates-tool-surveyors-spot-immediate-jeopardy



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