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.
The disclosures came during a pair of wide-ranging and remarkably candid town hall meetings Sowers held with hospital staff earlier this week. The Tampa Bay Times obtained and reviewed video of the meetings, which also illustrated the emotional strain the turmoil in the Heart Institute has placed on longtime staff members.
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.
That secrecy was shattered in November, when a Times investigation revealed that the unit’s mortality rate had tripled in just two years to become the highest in Florida.
Medical staffers began bringing concerns about two of the program’s surgeons to their supervisors in late 2015, the investigation found. But hospital administrators did not slow surgeries or make personnel changes until 2017.
The reporting led to the resignation of CEO Dr. Jonathan Ellen, two heart surgeons and the three vice presidents in charge of risk management, patient safety and communications.
It also led to inspections by state and federal regulators, who visited the hospital last month and placed it in a rare status called “immediate jeopardy.” Hospitals in that status lose public funding if they don’t fix the problems within weeks.
The reports from those inspections have not yet been made public. But Sowers said regulators made the immediate jeopardy determination because of the lapses in oversight, not because patients were in danger at the time of the mid-January inspection.
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.
Sowers described Ellen as wielding tremendous control over both the hospital and information about patient safety problems. Ellen held the roles of president, vice dean, physician in chief and director of graduate medical education. He had the power to set and approve the agendas for the board’s patient safety committee, Sowers said.
“Structurally, one person should never have that much power at the top of an organization,” Sowers said.
Ellen, a longtime Johns Hopkins faculty member who was sent to St. Petersburg to integrate All Children’s into the Johns Hopkins system, could not be reached for comment Friday. In April 2018, during an initial interview about the Heart Institute, Ellen told the Times his leadership team had been transparent. “If we found something that went wrong, we would notify our board, we would notify the right regulatory agencies, we would look at our processes,” he said.
Sowers said the hospital’s leadership structure is being changed to spread those responsibilities across more people and to better connect the hospital’s safety officials with administrators in Baltimore.
Checks and balances
All Children’s is governed by multiple boards. The hospital is owned by a branch of Johns Hopkins Medicine, which has a board of trustees in Baltimore. But All Children’s also has a local board of trustees, made up of prominent community leaders. Few have medical backgrounds.
It was the local board, hoping to raise the hospital’s profile, that decided to effectively give All Children’s to Johns Hopkins in 2011. Ellen was placed into power at the hospital shortly after. And the hospital revised its Articles of Incorporation to give Johns Hopkins near-complete authority to approve or overrule the local board’s decisions.
The local board now “really wants to understand what happened, and why they didn’t have the information” about the institute’s struggles, Sowers said.
“Just as you all mentioned that you are angry, some of them are angry, too, and they should be,” he said.
Sowers apologized to them, he said.
At Johns Hopkins Medicine, “they are just as upset, because they are trying to figure out how did people that we trusted not raise up the appropriate issues not only to the All Children’s board but not even to Baltimore,” he added.
Local board of trustees chairwoman Sandra Diamond did not answer questions from the Times about what the board knew about the Heart Institute. In a statement, Diamond said the board has “confidence in the current leadership and the efforts that have been taken to address communication and leadership process issues with the board.”
“We recently enacted new governance processes that ensure more rigorous checks and balances,” she added. “We are holding hospital leadership to high standards for our beloved institution.”
Former Progress Energy Florida CEO Vincent Dolan, who served on the local board until his term expired in 2018, described the situation differently than Sowers. In an email to a Times reporter, Dolan praised Ellen as “a person of great integrity” who prioritized safety. Dolan also said he was aware of the problems with the Heart Institute and had participated in “detailed discussions” about the topic on the safety committee and in board meetings.
“We were briefed about the Heart Institute issues — some of us in more detail than others. … I feel the Board was reasonably well informed,” Dolan said.
The federal government gave the hospital until Sunday to propose a plan for how it will address the issues. Sowers told the staff he was confident All Children’s would file a successful plan on time and its public funding would not be affected.
Failure to report
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.
Hospital leaders found the incidents by reviewing all of the Heart Institute’s cases from 2015 to 2018, spokeswoman Kim Hoppe later told the Times. Six were deaths, five of which were reported in the Times investigation, she said.
In the town hall meeting, Sowers said the hospital was reaching out to the families of all 13 children, as well as the other families profiled in the Times investigation, to apologize and provide support moving forward.
Sowers said the hospital had reviewed every death outside of the Heart Institute, as well. But it found nothing outside of the unit that needed to be reported, he said.
This wasn’t the first sign that All Children’s had failed to report serious problems.
Last year, the Times reported on two cases in which All Children’s surgeons had left needles in patients — a situation hospital officials are legally required to disclose.
In May, the state Agency for Health Care Administration cited the hospital for failing to properly report both incidents.
Nonetheless, in June the agency reported that All Children’s had corrected the issue and did not fine the hospital.
Asked Friday why the earlier investigation had cleared the hospital without unearthing any of the other unreported incidents, spokeswoman Mallory McManus said “additional information was brought to the agency’s attention that brought these incidents to light.”
‘Something this horrific’
Both town hall meetings also included lengthy question-and-answer sessions during which staff members voiced concern about how the crisis had affected the community’s trust in the hospital.
Was Sowers concerned board members would flee? (No.) How would he restore trust? (By being transparent, apologizing to the families who were hurt and following through on the action plan.)
Sowers was particularly troubled to hear cases of employees facing retaliation for speaking up, he said.
“People have real stories that they shared with me, and I have validated them and the stories actually did happen,” Sowers said. “And they are not proud moments in our history. That’s not okay.”
At times, the question-and-answer period gave way to emotional testimonies from long-time employees.
“For someone who has been here for 30 years, I’m pretty angry (at) our leadership and what they’ve done and sad for the people who are still here, doing the hard work,” one said.
Sowers said she had “every right” to feel that way.
“I can promise you that will get better having been through this before,” he added. “But it is part of the process you go through as an organization when something this horrific happens.”
Another veteran employee spoke about how hard he and his colleagues had worked to cultivate relationships in the community. He said community members are now “disgusted.”
“The unsavory, unpleasant fact of the matter is that people lied about the thing that should be most important to us,” the employee said. “I don’t have a constructive comment, I’m just telling you that, as somebody who has spent his entire life working for the benefit of this hospital, I am sick that this happened.”
Sowers asked if the employee was upset with him or the previous administration.
“I was here before Hopkins, okay?” the employee replied. “And I know what we had. We had a very good relationship with the people who ran the hospital. Everybody knew who was doing a good job and who wasn’t. If somebody did a bad job they were gone very very quickly. So if you are saying do I trust you? I have no reason to. You seem like a nice enough person. But you are standing in front of a Johns Hopkins sign there, and right now, based on my experience with Hopkins, that isn’t enough.”
Sowers said what mattered to him was acting in the best interest of children, not Johns Hopkins. He said Johns Hopkins had let All Children’s down.
“I just wanted to hear you say that,” the employee said.
The audience applauded.