New federal report details widespread problems at All Children’s

A federal investigation into Johns Hopkins All Children’s Hospital in St. Petersburg found failures in oversight that went far beyond the hospital’s Heart Institute.

A report released Friday criticized the hospital’s management structure, where virtually all authority rested with a few executives, and rebuked the board of trustees for not exercising proper oversight. It also detailed systemic problems with infection control.

All Children’s had been required to submit a plan for correcting the issues earlier this month. On Friday, All Children’s said the federal government had accepted its plan, found that the most serious problems had been addressed and lifted a threat to withhold public funding.

[ Click here to read all of the Times’ coverage of All Children‘s Heart Institute ]

Hospital leaders called the development “good news,” but said it was “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 said in a statement. “We must be vigilant and diligent every day and, most importantly, we cannot forget what happened here and what we have learned.”

The federal report comes three months after a Tampa Bay Times investigation uncovered a series of problems in the hospital’s heart surgery unit, where the infection rate had spiked and the death rate had become the highest in the state.

[ Read the investigation: Johns Hopkins promised to elevate All Children’s Heart Institute. Then patients started to die at an alarming rate. ]

The federal review took a broader look at the hospital. Inspectors determined that the board of trustees had failed to oversee infection control, physician competence and systems intended to improve quality.

During a town hall meeting for employees earlier this month, Johns Hopkins Health System President Kevin Sowers said hospital leaders had been aware of safety issues but did not “elevate (them) in appropriate ways to the board.”

The review also found that All Children’s did not track individual doctors’ outcomes and had no system for analyzing “data used to monitor the overall quality of care and patient safety.”

Instead, individual departments were responsible for analyzing their data and communicating problems to the patient safety committee.

Hospital employees knew about troubling deaths, but “the facility continued to implement ineffective strategies to ensure safe care,” the report found.

In the heart unit in particular, surgical site infections increased in 2017 and 2018. But when the hospital offered additional training on the topic in March 2018, none of the surgeons who were having problems attended.

Other departments saw an increase in infections and hand-washing fell off in 2018, according to the report. Inspectors determined the hospital “failed to provide a sanitary environment and identity, investigate and prevent potential transmission of infections associated with environmental sources.”

All Children’s also was cited for smaller infractions, such as failing to properly keep medical records, failing to properly document consent for procedures and not securing oxygen cylinders to their carts.

“If an oxygen tank explodes, it’s not a good thing. It’s a missile,” Sowers said during the town hall. “So I need your help in making sure that our oxygen tanks are secured.”

[ Read about the town hall: All Children’s says 13 heart surgery patients were hurt by care ]

Federal and state regulators visited the hospital in January. After, the federal government placed All Children’s in “immediate jeopardy,” a rare status that requires hospitals to fix issues within weeks to keep their public funding.

Only three hospitals across the country lost their funding last fiscal year.

A spokeswoman for the the U.S. Centers for Medicare and Medicaid said that the federal government would continue monitoring All Children’s progress.

In addition to the federal regulators, the Joint Commission conducted a recent site visit. The independent hospital accreditation organization “reported no findings,” an All Children’s spokeswoman said.

In an email to the Times, All Children’s Board of Trustees chairwoman Sandra Diamond said she was pleased the hospital’s plan to correct its problems had been accepted. She acknowledged there had already been “significant changes in leadership, systems and processes that support a more transparent governance and oversight of quality and safety.”

“The board has complete confidence in current leadership and the recent efforts towards greater transparency,” she said.

But U.S. Rep. Charlie Crist, who called for a federal investigation of All Children’s after the Times investigation, said it would take “a concerted, years long effort to rebuild the community’s trust in this institution.”

“For the families’ impacted, those wounds may never heal, and the hospital needs to be held accountable,” he said.

Crist said he and U.S. Rep. Kathy Castor would be meeting with the U.S. Department of Health and Human Services to discuss the situation next week.

The federal government’s key findings

Here are some of the citations from the inspectors’ 49-page report. Scroll down to read the full document.

• The hospital’s board of trustees failed to protect patients. The board did not properly oversee patient safety in areas like quality of care, medical staff credentialing and infection control. It hadn’t looked at survival data related to organ donors since January 2017, though it’s required to every year.
• The hospital did not track how well doctors were performing. A senior director told inspectors that the hospital did not “collect, track or trend any data” for individual physicians.
• All Children’s had widespread problems with communication. “There was no evidence of any lines of communication or accountability” between risk management and “any of the 17 committees, councils, and departments shown on the organizational chart as being responsible for the prioritization, development and deployment of clinical guidelines.”
• The Heart Institute failed to monitor surgeons’ competency. To obtain credentials, one surgeon provided data on 244 previous surgeries. But the hospital could not show it reviewed how often patients died or had complications after the procedures. The heart unit also had an increase in surgical site infections in 2017 and 2018.
• There were systemic failures in preventing infections. The hospital became worse at maintaining proper staff hand hygiene in 2018 but made no changes to improve. None of the five surgeons who had problems with surgical infection in 2017 and 2018 attended a training session for surgeons to prevent those infections. At least two of those surgeons were in the heart unit.
• Nine out of 10 inspected oxygen tanks were unsecured. “If an oxygen tank explodes, it’s not a good thing. It’s a missile,” said Johns Hopkins Health System President Kevin Sowers. 
• Several wheelchairs and toys were dirty. Wheelchairs that needed to be washed were kept unmarked near the patient entrance. The toy room did not have a system to ensure toys were cleaned regularly.

Responding to this list, a hospital spokeswoman said corrective measures had already been put into place for each of the findings. Among them, hospital leaders had established “competency-based metrics” to measure physician performance and re-educated the team on surgical site infections, hand hygiene and environmental disinfection. The hospital had also acquired new spring-locking mechanisms that secure oxygen cylinders to their carts. The complete plan of action that the hospital submitted to the federal government was not immediately available.