California has been withholding money from 66 hospitals it holds culpable for medical errors, but state officials refuse to describe the mistakes or publicly identify the hospitals, all of which have allegedly harmed patients.
California Department of Health Care Services spokesman Norman Williams said the agency is withholding disciplinary records to protect patients’ private medical information, but patient advocates are criticizing the lack of transparency.
“I mean, can you imagine if a plane were to crash and they said, ‘Oh, we can’t tell you what the airline was?’” said Erica Mobley, spokeswoman for the non-profit hospital rating organization The Leapfrog Group.
In the last 13 months, the California Department of Health Care Services has withheld nearly three-quarters of a million dollars in Medi-Cal reimbursements to hospitals that state officials hold culpable for medical errors.
Alicia Cole, of Los Angeles, said one such error devastated her. In 2006, she checked into Providence Saint Joseph Medical Center in Burbank to have noncancerous growths removed from her uterus, a surgery that is generally considered routine.
But several days after the procedure, Cole’s abdomen was red and swollen, with a brown fluid oozing from her surgical incision. She would later be diagnosed with necrotizing fasciitis, according to a state Department of Public Health report. The disease, commonly described as being caused by “flesh-eating bacteria,” destroys skin, muscle and underlying tissue. On five separate occasions in August and September 2006, Cole underwent surgeries to remove infected and dying tissue.
A follow-up report prepared for the federal Centers for Medicare and Medicaid services states “the facility failed to provide a sanitary environment that would avoid sources and transmission of infections and communicable diseases… There was no evidence of surveillance which included preventive, early detection, control, education, and/or investigation of infections.”
The report goes on to describe medical personnel entering the operating room (not during Cole’s procedure) in street clothes instead of protective garb. In another instance, an anesthesiologist began work in the room while wearing a dirty fleece vest, the report states.
It describes a plastic sheet protector for notices on the operating room door that was “full of dust and dirt.”
Once, when the operating room was being prepared for surgery, compression devices for the patient’s legs fell onto the floor. They were put back onto the operating room table and used
on the patient later, according to the report.
Had she read that report, Cole said, she never would have consented to surgery at the Medical Center. Eight years after her infection, she says her injuries cause her constant pain.
Federal sanctions coming
The California hospital sanctions — mandated by the Affordable Care Act — may foreshadow a national crackdown on hospital errors by the federal Centers for Medicare & Medicaid Services.
Starting in October, federal authorities will start withholding 1 percent of Medicare inpatient payments from hospitals with the worst rates of Hospital Acquired Conditions — government jargon for medical mistakes such as giving a patient a transfusion with the wrong blood type, letting patients fall and hurt themselves and failing to prevent surgical site infections.
The Provider Preventable Condition rules that California is enforcing roughly encompass the same mistakes.
With both the federal and the state program, the premise is the same: just as someone wouldn’t expect to pay a plumber or a mechanic for botched work, health care regulators shouldn’t tolerate slipshod hospitals.
There’s one big difference between the national program and the state’s: Whereas the federal CMS has published a preliminary list of hospitals that fall short and provides a website where people can look up records on institutions, California’s Health Care department provides no comparable resource.
The California Department of Public Health has found a way around the type of privacy concerns that the Health Care agency is citing in its refusal to disclose the records. It offers a website with reports on actions taken against hospitals. Personal information is redacted.
Other states go further. In Minnesota, for example, hospitals are required to report on 29 “adverse events,” to a central repository within 15 days of occurrence and deliver a correction plan within another two months. State authorities compile an annual report, with hospital-by-hospital descriptions of such events, said Rachel Blake Jokela, the state’s adverse health events program director. Event summaries and more detailed reports are available online.
Concerns over lack of information
Patient safety activists say they’re skeptical about the Health Care department’s reticence to disclose the hospital sanction information.
“Anybody who knows that the patients they’re working with are informed and empowered and are asking hard questions, anybody in that position is going to up their game,” said Julia Hallisy, president of The Empowered Patient Coalition, a San Francisco-based advocacy group. “That’s the whole idea behind the Affordable Care Act’s emphasis on transparency.”
Likewise, patients’ rights groups had hoped that government penalties would provide a financial incentive for better hospital practices, Hallisy said. She called the $700,000 assessed against hospitals since July 2013 “a pittance.”
Mobley, with The Leapfrog Group, said the agency’s invocation of patient confidentiality concern “doesn’t pass the smell test.”
She said the department isn’t alone in refusing to disclose information relevant to patient safety. Currently, her organization is wrangling with CMS over alterations to Hospital Compare, the federal site that provides information about hospitals nationwide. Earlier this month, regulators deleted several categories of details from the site, including a tally of foreign objects left in patients’ bodies.
“The standards of transparency in health care are not like those you would find in any other industry,” she said.
Activists also cite a study in the Journal of Patient Safety, which estimated last year that the number of premature deaths associated with medical errors was approaching 400,000 a year. That’s more than four times higher than the 98,000 annual deaths estimated in a 1999 Institute of Medicine study.
Hospitals say internal monitoring is sufficient
On the other hand, Martin Makary, an associate professor of surgery at Johns Hopkins University and author of a book about transparency in health care, endorsed the decision to withdraw some data.
Even though that might seem like a setback to hospital transparency, Makary said, “the truth is, from a pure statistical methodology standpoint, the data’s just not very valid.”
He said mistakes like leaving foreign objects in surgery patients are so rare that “if it’s 50 percent higher at one institution than another, that can be misleading.”
Further, Jan Emerson-Shea, vice president for external affairs at the California Hospital Assn., said monitoring programs by watchdog groups don’t all use the same methods, which can be confusing.
The association’s own internal monitoring points to broad improvements in patient safety, Emerson-Shea said.
Julie Morath, president and CEO of the association’s Hospital Quality Institute, said participants in an institute program reduced ventilator-associated pneumonia by more than half over a two-year period. Central line-associated bloodstream infections are down 43 percent, and some 30 hospitals have gone more than a year without a single such infection, she said. Bedsores are down 58 percent.
Devastated by a medical error
But Cole still wishes hospitals’ rates of medical errors were more public.
The former actor has kept a photo showing her lying in her hospital bed after one of her surgeries to remove some of the infected skin and tissue on her abdomen. The skin on the left side of her stomach is largely gone, and the underlying flesh looks like it’s been mauled.
Public Health officials conducted two inspections in response to complaints about the case. They found Providence Saint Joseph had failed to follow its policy on monitoring and controlling hospital-acquired infections.
The report found that the hospital employee responsible for tracking and containing infection didn’t know about two patients with infections. Three people at the hospital had also entered an operating room without donning full protective garments, including an anesthesiologist who carried a bag into the room and was not wearing hair covering, protective booties or a surgical mask.
An inspection of an operating room being turned over and cleaned for another case revealed paper postings inside plastic sheet protectors hanging on every wall and doorway. Hospital tape was used for many of these postings, including cloth tape, which was visibly dirty. One sheet protector was “full of dust and dirt,” the officials found.
Records show Providence Saint Joseph submitted and adhered to correction plans. Hospital spokeswoman Patricia Aidem responded to questions about Cole’s case via email.
“The hospital’s response has long been: ‘She was not injured at Providence Saint Joseph Medical Center nor did she acquire an infection at our facility,’” Aidem said.
Cole, who recently earned a graduate certificate in healthcare management and leadership, gives lectures and works as a safety consultant to hospitals.
She said she doesn’t have the stamina today to resume her acting career. But she often thinks back to the time when she was so healthy that her image was featured on billboards for an anti-obesity campaign.
“Sometimes I pray, asking God, ‘Oh, I wish I could have my body back again the way it was, just for 10 minutes,’” she said.