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DMC talks new instruments, fixes in health hearing

Karen Bouffard

Detroit Medical Center leaders testified Wednesday before the state House Health Policy Committee, outlining multiple efforts to fix problems with dirty surgical instruments uncovered by The Detroit News last August.

The health system leaders said they streamlined the cleaning process and invested in new instruments following a six-month Detroit News investigation that found the DMC’s Midtown hospitals were plagued with dirty, broken and missing surgical instruments for more than decade.

CEO Dr. Anthony Tedeschi explained how the DMC has been reconfigured top to bottom to ensure surgical instruments are available and properly cleaned.

“We’ve added both front-line staff and management staff. We’ve invested in new equipment. We’ve invested in new instruments, and probably as important as anything, we’ve engaged around the care we provide and improving it,” Tedeschi told lawmakers. “Throughout this process we’ve worked closely with our regulatory and accrediting agencies. We are meeting the industry standards.”

State Rep. Hank Vaupel, R-Fowlerville, chairman of the health policy committee, said the health system was asked to testify simply because “we’ve had so many questions about what’s happening at the DMC.” No legislation has been proposed.

The committee also heard from Larry Horvath, director of the Bureau of Community and Health Systems, part of the state Department of Licensing and Regulatory Affairs, which investigated the instrument problems at the DMC. The agency also conducted a federal investigation on behalf of the Centers for Medicare and Medicaid Services.

Horvath provided an overview of LARA’s responsibilities, but didn’t discuss results of their state and federal investigations. The agency found multiple violations of state and federal infection control standards. Health system hospitals have since passed inspections and are in compliance with regulations.

State Rep. Andy Schor, a Lansing Democrat on the House committee, said he was satisfied that the DMC is correcting its problems, but would like to have heard details of the LARA investigation.

“We were not presented with a whole lot of specific allegations. It’s not like anybody said, ‘What about this instance.’ None of that was really provided to us,” Schor said.

Asked about the brevity of Horvath’s presentation, LARA spokesman Jason Moon said: “The Legislature requested that LARA give a brief overview of the department’s regulatory oversight of hospitals in Michigan and Mr. Horvath kept his testimony in line with the Legislature’s specific request.”

Bret Jackson, president the Economic Alliance for Michigan, a business/labor coalition that focuses on health care issues, said he’s confident the DMC has made the necessary changes, but Michigan needs greater transparency about health care safety issues. Twenty-eight states have laws requiring hospitals to report mishaps that could have endangered the health of a patient, but Michigan is not among them.

“The DMC health system has the expertise and knowledge of how to deliver high quality and very safe care to patients. It was very clear today that they’re very committed to this issue and will be vigilant in the future,” Jackson said.

“At some point in the near future, we’d like the Legislature to understand this doesn’t just happen at DMC. There are other hospitals where adverse events happen and the public should know what events are happening and where it’s taking place.”

Dr. Joseph Lelli, chief surgeon at Children’s Hospital of Michigan, told the committee that the DMC’s problems appeared worse than they were due to vigilant internal reporting of such incidents. He said doctors and employees increased internal reporting several years ago when the DMC decided to become a “highly reliable organization,” a process he said is used by airlines and some other industries to improve safety.

“There was a huge increase in reporting of what we called defects that could be potentially misconstrued as potentially injuring a patient,” Lelli said. “We decided on this journey that we were going to start reporting that, and there was a significant increase in reporting that probably raised concerns that there was an increased problem getting to the patients.”

The News exposé was based on 200 emails and internal reports that revealed the issues had complicated operations including brain surgeries, heart repairs and spinal fusions, kept patients under anesthesia unnecessarily and led to cancellations of dozens of operations. The DMC has maintained that no patients were injured by instruments marred by visible blood, bone or other contaminants.

During the News’ investigation, four DMC surgeons said they encountered improperly cleaned, missing or incomplete sets of instruments about once a month or more. At other hospitals, the problems are less common, said the doctors, who spoke on the condition of anonymity, fearing job reprisals.

The state in mid-September cited the DMC for eight violations of the state public health code, mainly due to infection control problem and lax staff training.

A concurrent investigation conducted by LARA on behalf of the federal Centers for Medicare and Medicaid Services found the DMC in violation of federal rules because of chronic problems cleaning instruments.

The state and federal agencies closed their investigations in December after the health system passed an inspection, but CMS launched a second investigation in January after the News reported that a surgery patient had been exposed to a dirty instrument just one day after that inspection was passed. That investigation also was closed.