Federal regulators have issued a report faulting the Detroit Medical Center for numerous problems sterilizing surgical instruments and given the system until mid-December to fix them or lose Medicare and Medicaid funding.
A Centers for Medicare and Medicaid Services investigation prompted by The Detroit News concluded the DMC’s Midtown campus “failed to implement aseptic cleaning procedures in operating rooms” and “failed to develop and/or implement infection control policies and procedures.”
The 13-page report made public Tuesday sets in motion what is known as “termination proceedings,” meaning that DMC is now out of compliance with federal standards and must remedy them to keep federal funding. That comprises a significant portion of the system’s revenues, but an exact amount wasn’t known Tuesday night.
The DMC is set to lose federal funding on Dec. 14 unless a surprise inspection before then finds all the problems fixed, according to CMS. Among other issues, documented in a two-day investigation in late August: One of three sets of instruments opened by regulators was improperly sterilized and routine steps to clean tools were skipped.
“The (DMC) failed to ensure staff received education and were deemed competent in infection control policies and procedures ... resulting in the potential for unsatisfactory patient outcomes for all surgical patients,” the report read.
It documented workers putting dirty gloves back in a box with clean ones, mopping blood-stained floors without moving cleaned equipment, failing to wipe blood off surgical instruments while collecting them for cleaning, neglecting to perform audits of cleaned equipment or require workers undergo training and failing to soak tools after surgeries — a basic step in the sterilization process.
The report, completed Oct. 3, wasn’t made public until the federal government accepted the DMC’s plan to correct the problems. Anticipation of its release set off meetings with union officials and the hiring of technicians to clean surgical tools. The DMC is forming an improvement council and task force to “improve operational protocols and sterilization processing.”
“We take the survey results very seriously and through the collective efforts of our management, partners and employees, we will take all actions necessary to correct the findings,” the DMC said in a statement Tuesday.
“The trust of our community is paramount as we continue to build on our 150 year legacy of quality care to the residents of Detroit.”
The investigation found problems with both sides of the cleaning process: the operating room, where tools are supposed to be soaked and cleaned, and the central sterile processing department in the basement of Detroit Receiving Hospital that processes thousands of instruments per day for Receiving, Children’s, Harper University, Hutzel Women’s and DMC Heart hospitals.
That department was the focus of a Detroit News series in late August documenting 11 years of internal complaints about dirty instruments that complicated operations from brain surgeries to spinal fusions, kept patients under anesthesia unnecessarily and led to cancellations of dozens of operations. The News found that the DMC’s for-profit owner, Tenet Healthcare of Dallas, Texas, had been made aware of the issues.
The articles were based on 200 pages of internal emails and incident reports that showed doctors feared for patients’ safety because of unsterile, broken or incomplete instrument sets. As recently as last summer, Children’s Hospital of Michigan chief surgeon Joseph Lelli wrote in an email that “we are putting patients at risk frequently.”
Instrument designer stunned
Jim Schneiter, a Chicago-based instrument designer and expert in sterile processing, said he was “stunned” and “coming off his chair” while reading the report Tuesday.
“This is insanely basic stuff — people don’t do things this foolish even at home,” said Schneiter, owner of America’s MedSource, which develops and patents surgical equipment and licenses them to manufacturers.
One worker told inspectors, “We never wash or soak the instruments in the OR, just spray them and hold them in this cart until they can do the massive cleaning downstairs.”
Another admitted training records were thrown away when a manager left the department. The records that were available showed fewer than half of employees attended some training sessions.
Yet another told the inspectors the hospital hadn’t conducted any infection control audits since 2015. An operating room technician told investigators he visually inspected instruments for blood and didn’t bother soaking them unless they looked bloody. Another told an inspector that “removing residual bioburden on surgical instruments was a lower priority problem.”
One tray of instruments was spotted leaving an operating room without any enzyme solution, a necessary step to prevent blood from caking onto instruments before cleaning. And when investigators opened three instrument trays, they found one that contained retractors found in closed positions with instrument surfaces touching, a violation of protocol that ensures all surfaces of tools are sterilized.
The DMC is allowed to continue operations while it addresses the issues. Under federal rules, terminating funding is the only recourse when hospitals are found to be out of compliance, according to CMS rules.
Only the state Department of Licensing and Regulatory Affairs has the power to stop surgery.
“If I had the ability I would not let a patient go in there until there’s a lot of re-education, retraining and personnel changes,” Schneiter said.
“What I keep reading in this report is ‘We have a culture that has other priorities.’ That’s what’s tearing at my heart more than anything, when I think of all the patients that have been harmed over all these years because of this lackadaisical attitude.”
Improperly sterilized instruments can cause a host of problems, from infection to septic shock. The DMC has maintained that no patients were harmed because of the problems and that its quality control systems ensured that patients didn’t come into contact with dirty tools.
DMC hired a private company, Unity Healthtrust of Alabama, to manage sterilization operations in June. Another company is coming on board soon to verify that all instruments are sterilized.
The federal investigation was conducted by LARA, which last month cited the DMC for eight health code violations due to lax training of sterilizing workers. The DMC has until mid-November to submit a plan to correct those findings or face a penalties including fines or suspensions.
As recently as this month, doctors told The News they still encountered dirty or rusty tools in operating rooms.
William Broman, a Republican candidate for the state House, issued a statement criticizing state regulators for allowing surgeries to continue and calling on lawmakers to host hearings.
“We need to prevent further acceptance of mediocrity from state departments,” said Broman, who is campaigning for District 1 that represents Detroit, Harper Woods, Grosse Pointe Woods and Grosse Pointe Shores.
Jason Moon, communications director of LARA, did not respond to a request for comment on Tuesday.
Addressing the problems
The federal report was released on the eve of a planned meeting with union officials about sterilization issues. The DMC did not inform the unions about the consequences of the report, said Al Garrett, president of the American Federation of State, County and Municipal Employees Council 25.
“There’s no question: We are committed to getting this done and fixing the problems,” said Garrett, whose union represents sterilizing workers along with the Service Employees International Union Healthcare.
“The stakes are too high to our members and to the community.”
The DMC is hiring more sterilizing workers and the department now has 87 technicians. That’s up from about 75 this summer, but short of the 105 about 10 years ago. Labor is also concerned about recent management turnover, as two administrators of the department have left since summer, Garrett said.
The department is managed by four unions, three AFSCME locals and one of Service Employees International Union Healthcare. The DMC had planned to meet with Garrett and his counterpart at the SEIU, Marge Robinson, on Wednesday but unions want to reschedule it until next week to include local leaders who have better knowledge of the situation, Garrett said.
“They are doing some work to improve the facility, but there’s still a shortage of staff,” Garrett said. “It’s not the progress we want to see.”
Melanie Moss, a DMC spokeswoman, said “we are working diligently to improve efficiencies and processes in CSP to maintain our community’s confidence.”
The hospital is revamping policies, increasing education and training, and hosting regular meetings to solve the problem, according to the DMC’s corrective action report.
Community leaders are closely monitoring the issue, said the Rev. William Revely, chairman of Unify Detroit Coalition, a nonprofit group that sponsors health fairs and meets quarterly with DMC officials to discuss community concerns.
“We’re definitely concerned,” Revely said. “We trust the DMC to do right, but Tenet isn’t always known as the best in terms of dealing with the community.”
Twitter: @joeltkurth; @kbouffardDN
Among the findings, the report cited:
■Surgical instruments were improperly sterilized
■Poor worker training
■No infection control audits
■Operating room technicians failed to soak equipment
■Dirty gloves put with clean ones. Blood-stained floors improperly cleaned.