The law firm investigating All Children’s filed its report. The hospital will make big changes.

The investigation was commissioned by the board of Johns Hopkins Medicine, which runs the hospital, following a Times investigation into fatal problems in All Children’s heart surgery unit.
Johns Hopkins All Children's Hospital, St. Petersburg. [SCOTT KEELER   |   Times]
Johns Hopkins All Children's Hospital, St. Petersburg. [SCOTT KEELER | Times]
Published June 28, 2019|Updated June 28, 2019

Johns Hopkins All Children’s Hospital will make sweeping changes to its policies and structure in response to problems in its heart surgery unit, Johns Hopkins announced today.

The changes include new checks and balances on the hospital’s president, more rigorous evaluations for top executives, better tracking of internal complaints, more thorough vetting of doctors and improved monitoring of patient safety and quality metrics.

Top executives will now report to both the hospital president and Johns Hopkins Health System leaders in Baltimore. And officials in Baltimore will be more involved in hiring, firing and discipline in St. Petersburg.

The new policies come after the Tampa Bay Times exposed serious problems in the hospital’s heart surgery unit, including a sharp increase in surgical mortality and complications.

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

Late last year, the Johns Hopkins Medicine board hired the law firm Gibson Dunn to investigate the unit. Johns Hopkins officials promised to “share lessons learned from the review.”

Gibson Dunn reviewed more than 140,000 documents and interviewed 119 people. It said it said it briefed the All Children’s and Johns Hopkins Medicine boards on its “detailed observations” at meetings in March, April and May.

On Friday, Johns Hopkins released a 12-page memo with the firm’s recommendations for improvement. Health system President Kevin Sowers said the All Children’s and Johns Hopkins Medicine boards had already approved the suggestions and that the hospital would hire an external monitor to make sure they happen.

Related: Family settles for $2.3 million over All Children’s heart surgery death

System leaders will analyze whether the same steps are needed at the five other Johns Hopkins hospitals, Sowers said.

Sowers said the firm discovered a culture of “fear of retaliation and retribution” across the hospital but determined that the quality and safety issues were limited to the heart unit.

Sowers declined to release the detailed findings from the firm’s investigation.

“The story has really already been told,” he told the Times in an interview. “You’ve been a part of telling that story. The question I think our board was looking at was: What were the people failures, the system failures and the process failures that we could learn from and become a better organization so this would never happen again?”

Some of Gibson Dunn’s recommendations echoed findings from federal regulators, who showed up at All Children’s in January and found that too much power rested with the hospital’s president.

Other recommendations addressed key findings in the Times report.

One example: The Times reported that procedures started going wrong after All Children’s became part of the Johns Hopkins network and hospital leaders made a series of personnel changes within the Heart Institute.

The firm recommended “more strategic planning” when changing clinical programs and more quality monitoring during transitions, especially for units that handle complex procedures.

It made the point bluntly: “In making personnel decisions, consider the effect on team dynamics.”

The Times also reported that hospital leaders had failed to report safety incidents to the appropriate regulatory agencies. Sowers said former employees had used concerns about malpractice lawsuits “as rationale as to why things weren’t being reported.”

Gibson Dunn suggested that All Children’s develop “a clear disclosure policy that prioritizes sharing, disclosing or reporting information,” regardless of the concern for legal risk.

In another story, the Times reported the six Johns Hopkins hospitals had not consistently followed safety practices championed by the system’s Armstrong Institute for Patient Safety and Quality.

[ Read: Johns Hopkins wrote the rules on patient safety. But its hospitals don’t always follow them. ]

Gibson Dunn called for the system to consider expanding the institute’s emphasis “from a focus on education and research to include a focus on patient safety within the health system, with accountability for hospital residents regarding relevant operational matters.”

Sowers said the hospital had already acted on at least one of the recommendations: detailed tracking data for programs and individual physicians on a regular basis. Hospital leaders have examined the heart, neonatal intensive care and congenital diaphragmatic hernia units, he said, and are now looking at the bone marrow transplant unit.

“There’s a series of programs that we’re going through and that’ll be done on an annual basis,” he said.

Gibson Dunn also recommended “structured, automated data processes to counteract the possibility of health care providers and leaders not sharing information.”

Sowers said the new steps will help ensure problems come to light sooner. He said health system leaders in Baltimore did not fully understand what was happening in the All Children’s heart program until late last year. When they were presented with all the facts, they acted quickly, he said.

Sowers said he believed he had already made “appropriate changes” to the hospital’s leadership; six top officials resigned after the Times story published. But if additional problems were discovered, “I’m not saying that there wouldn’t be other changes,” he added.

[ Read more: Top All Children’s executives resign following Times report on heart surgeries ]

As All Children’s carries out the policy changes, it will also work to address systemic problems flagged by the federal government. Hospital leaders recently agreed to hire an external consultant to oversee improvement for 12 months in order to maintain public funding.

Separately, a team of national experts has been working on a plan to restart the heart surgery program. Sowers said the team had drawn up recommendations and given them to the board. But he said he did not have a timeframe for surgeries beginning and that the program would first need to hire another surgeon.

Read the full list of Gibson Dunn recommendations here:

Staff writer Justine Griffin contributed to this report.

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