DMC passes new inspection in surgical instruments case

Joel Kurth and Karen Bouffard
The Detroit News

Detroit Medical Center officials announced Tuesday that the hospital system passed a surprise inspection of its sterilization facilities and no longer violates the state health code.

The Dec. 22 inspection was prompted by a series of Detroit News articles showing the hospital system’s Midtown campus struggled for a decade to properly clean instruments.

Following the articles, the state’s Department of Licensing and Regulatory Affairs cited the DMC for eight health code violations that it said “placed patients at risk and delayed procedures due to unclean or contaminated instruments and equipment.” The re-inspection found no issues, ending a threat of fines.

“We are pleased that we resolved this matter to LARA’s satisfaction and that the hospital is in compliance with regulations designed to protect the health and safety of patients who entrust us with their care,” the DMC announced.

DMC officials would not comment further and declined The News’ request to interview CEO Joseph Mullany.

Most of the resolved state health code violations involved lax training. Among other things, the state initially found employees had been absent for continuing education sessions about instrument cleaning.

LARA spokesman Jason Moon wrote in an email Tuesday that the findings mean “LARA’s investigations into DMC’s central sterile processing are now closed.”

Even so, union leader Donna Stern said the workplace problems that led to the dirty instruments haven’t been fixed. The DMC hasn’t invested in new surgical tools and equipment, she said, and workers are under pressure to assemble surgical sets with dozens of instruments and sometimes can’t do so in time.

“The changes have been superficial. They’ve painted the department. There are new layers of supervisors. But not the things we need to do our jobs properly,” said Stern, unit chairwoman of the American Federation of State, County and Municipal Employees Local 140, one of four locals that represents sterilization workers.

The results of the Dec. 22 inspection remove the last significant regulatory hurdle addressing the problems at the DMC’s Midtown campus, which is comprised of Children’s Hospital of Michigan, Detroit Receiving, Harper University, Hutzel Women’s and DMC Heart hospitals.

One department cleans millions of surgical instruments per year for the hospitals. The News’ investigation, which was based on 200 pages of emails and documents, showed unclean tools complicated operations from appendectomies and brain surgeries to cleft palate repair and spinal fusions, kept patients under anesthesia for up to an hour and canceled dozens of operations.

After the August series, the Centers for Medicare and Medicaid Services deemed the DMC out of compliance with its rules and threatened to sever its federal funding, which totaled $705 million last year, if the problems weren’t fixed by Dec. 14.

The initial federal inspection, which was conducted by LARA regulators, concluded the DMC “failed to implement aseptic cleaning procedures in operating rooms” and “failed to develop and/or implement infection control policies and procedures.”

One in three sets of instruments opened by regulators during the inspection wasn’t properly sterilized.

The inspection 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 initial inspections prompted a flurry of reforms, and federal authorities in November deemed the DMC back in compliance.

Among other initiatives, the DMC outsourced the management of its central sterilization processing department, hired new technicians to clean instruments, revamped policies, created internal committees to constantly monitor instrument cleaning and entered into an agreement with the state to fix the issues.

“There was a zillion meetings,” said Stern, the union chairwoman. “Workers don’t want meetings. They want results. Morale is still quite bad in the (sterilization) department.”

The DMC did not respond to her statements. The hospital system has maintained that no patients were harmed or infected because of dirty instruments but has declined to release confidential records to prove the contention.

Erica Mobley, spokeswoman for The Leapfrog Group, a Washington, D.C.-based nonprofit that grades hospitals on quality and safety measures, said it is incumbent on the DMC to maintain improvements.

“We hope that the DMC has implemented process improvements and leadership changes … and that they will not be reverting to these previous practices,” Mobley said.



Twitter: @joeltkurth, @kbouffardDN