The leader of the state and federal probe of the Detroit Medical Center questioned the capability of his staff to investigate dirty instruments, acknowledging their “expertise is limited,” emails acquired by The Detroit News show.
Through the Freedom of Information Act, The News obtained 220 pages of emails that shed light on the early days of an ongoing investigation into the DMC that was prompted by a series of articles in the newspaper.
“I am searching the (public health) code to see what options we may have, as our expertise is limited (in) this specialized area,” Larry Horvath, director of the Bureau of Community and Health Systems, wrote in an Aug. 30 email to Mike Zimmer, Snyder’s cabinet director.
The emails show Gov. Rick Snyder’s top aides sought an investigation and were provided wrong information by Horvath.
When Zimmer inquired about possible penalties to the DMC, Horvath replied: “We really don’t have authority state or federal to issue fines against hospitals.”
In fact, the state can issue fines of $1,000 per day for each health code violation. The state cited the DMC for eight outstanding violations on Sept. 15. Had the state pursued fines, then, the tally would now be $600,000.
Those are among the new details in emails that also show the DMC uses less-reliable cleaning methods to compensate for equipment shortages, and had its lobbyist reach out to state officials on the first day of the investigation. Coupled with earlier revelations that the state missed dirty instruments during a 2015 inspection — even as doctors complained about them — the emails have some questioning the probe’s integrity.
“It’s very troubling, especially since the state is supposed to be the quasi-policing agency,” said state Sen. Bert Johnson, D-Highland Park. “There’s no excuse for the state to not have expertise. It has to be equipped to protect the public.”
Jason Moon, communications director of the Department of Licensing and Regulatory Affairs, said last week the state “does have the expertise” to conduct the investigation. The state brought in an outside contractor — CleanStart Surgical of Plymouth — as an “extra precaution” to assist, Moon said.
An agreement between the DMC and LARA calls for CleanStart to verify all surgical tools are properly cleaned and report to the state every 10 days.
As for the fines, Moon said Horvath misspoke. A “thorough review” of the law found the state could fine hospitals if they brought the issue to court, an option the state didn’t pursue, Moon said.
The emails released to The News, however, don’t show any evolution into thinking about either fines or whether state employees were qualified to conduct the investigation.
That’s because the state refused to release numerous emails and reports, arguing that “frank communications” by its employees outweigh public interest in knowing how the probe was conducted. The News is appealing.
The emails that were released show:
Equipment shortages: The state pursued no violations against the DMC for cleaning surgical sets with a method that experts say should be used only in emergencies.
“They ‘flash’ sterilize, which is not a recommended practice and should be avoided if possible,” Horvath wrote to Zimmer on Aug. 30.
“For example, they scheduled 3 elective surgeries pretty close together that needed the same instruments, and the DMC only had two of these devices. So they needed to ‘flash’ sterilize so they could use for the next surgical case.”
Also known as “immediate use sterilization,” flash cleaning should be used in “emergency use situations only — like if someone is bleeding to death” or if a tool drops mid-surgery, said Donna Swenson, president and CEO of Sterile Processing Quality Services of Illinois, who helped develop national best practices about instrument cleaning.
The cleaning method increases the risk of infection, Swenson said. Typical sterilization takes hours and involves soaking, scrubbing and steaming equipment before allowing it to dry. Flash sterilization takes minutes and eliminates the drying stage, leaving them wet and vulnerable to contaminants, Swenson said.
“Lack of inventory is not a good reason for immediate use sterilization process,” Swenson said. “You need to go out and buy new instruments.”
Moon said flash sterilization is “an acceptable technique” and not subject to penalty.
The DMC did not respond to requests for comment from The News about its use of the sterilization technique.
Lobbyist inquiry: The DMC’s lobbyist, Jeff McAlvey, requested a meeting with Horvath and his boss, Shelly Edgerton, director of LARA, on the first day of the investigation.
“An ongoing investigation does not prohibit us from meeting and listening,” Horvath wrote to Edgerton on Aug. 29.
McAlvey told The News the meeting never occurred because the investigation had already begun. Moon said “LARA is always available to meet with providers.”
Jahan Azizi, retired clinical engineer for risk management at the University of Michigan Health System, said the request is inappropriate.
“It’s sad. If you’re sending in your lobbyist, then you already know something is wrong,” said Azizi, who has worked with the U.S. Food and Drug Administration on probes related to improperly cleaned surgical tools.
“This went on for a decade. Just do it right the first time.”
The emails show Jamie Zaniewski, a senior strategy adviser to Snyder, met with the DMC on Aug. 31, the morning after the conclusion of the two-day inspection. She did not respond to requests for comment Monday about the nature of the meeting.
Internal debate: Staffers exchanged web links of The News’ investigation the morning it was published and debated whether to investigate.
“I know media stories are many times skewed and we hesitate to investigate,” Heather Hosey, of LARA’s complaint intake unit, wrote to several staffers on Aug. 25.
“However, this article does have dates and names, which potentially gives it more credence.”
Less than 20 minutes later, Horvath replied: “Is this related to the bug issues around the drains? Or is this more issues that you already cited that they are attempting to correct? At least we can say we have been addressing it for some time now.”
It’s unclear what Horvath was referring to. The state had cited the DMC’s sterilization facilities in March 2015 for seven deficiencies but none involved bugs or dirty equipment.
The thinking had changed by that afternoon. Anna Heaton, Snyder’s press secretary, wrote Zimmer at 3:14 p.m., saying the “information in the article is staggering.” Zimmer then asked Edgerton if regulators “could open an investigation based on this media report.”
“Already in progress,” said Edgerton, the department director.
Horvath also led a federal investigation on behalf of the Centers for Medicare and Medicaid Services, which found the DMC out of compliance with federal standards.
In November, DMC passed a re-inspection, eliminating a threat of losing more than $500 million in federal funding.