Sparrow Hospital cited for 'patient safety'

Accrediting agency finds multiple deficiencies


A national organization that accredits Sparrow Hospital has issued a preliminary denial after finding scores of deficiencies during a recent unannounced safety inspection.

The accrediting organization, called The Joint Commission, “cited us for more than 90 concerns,” according to a May 22 email from Candace Metcalf, the hospital’s chief of medical staff, to staff members.

“Some of these were relatively minor, others were directly related to patient safety,” she wrote. “We were given three weeks to institute changes and were resurveyed last week. Last week’s survey went well, however due to the severity with some of the citations, we will continue to be resurveyed throughout the summer and the next couple of years.”

City Pulse obtained Metcalf’s email from a source who asked not to be identified.

The Joint Commission is an independent nonprofit that inspects and accredits about 80% of U.S. hospitals. It issued a preliminary denial of accreditation to Sparrow Hospital on April 20, a day after a surprise inspection.

Joint Commission accreditation allows Sparrow to “participate in” Medicare and Medicaid, according to Metcalf. The commission report, which is available online, lists 48 “standards” that the inspection found to be “out of compliance,” such as:

  • “The competence of staff to perform their responsibilities.”
  • “Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • “It informs and educates the patient about his or her follow-up care, treatment, and services” before discharging or transferring them.

It also cites the discovery of various unlabeled medications and a failure to identify patients at risk of suicide.

The commission’s report also found that patient wait times for admission were far above national medians.

In her email, Metcalf told medical staff that Sparrow needs its physicians to address these matters:

  • “Brief operative notes must be completed before the Patient leaves the operating or procedure room.”
  • “Anesthesia carts must be locked. Please establish this as an ongoing habit, not just something we do when we are expecting an inspection. We may not know when inspectors will appear.”
  •  “Time-outs” — the final check by medical personnel before a procedure on whether they have the right patient and understand what they are doing — “must be done by the privileged provider, not by Caregivers before the Physician is present. All participants in the time-out must be attentive to the time-out and not talking, prepping, charting, or draping, etc. It is expected that we are active participants in the process.”
  • "Surgical attire (bouffant hats and shoe covers) should not be worn outside the unit.”

Sparrow spokesman John Foren declined to release an itemized list or provide details about the deficiencies, but he assured City Pulse that “all concerns have been corrected and cleared.”

A spokeswoman for The Joint Commission pointed to online records but also declined to elaborate further, citing “the privacy of all involved.”

Neither Metcalf nor any other officials at Sparrow could be reached for an interview. The hospital is still flagged with “preliminary denial” in online records published by The Joint Commission.

Foren maintained the hospital “remains fully accredited” according to the commission’s standards.

“We are steadfast in our commitment to meeting the highest standards for safety and quality,” according to a one-paragraph statement from Sparrow. “We certainly appreciate TJC for their comprehensive approach to regulating hospitals and it is common for them to find issues that are reasonable and straightforward to correct.”

The commission issues “preliminary denial” when hospitals either create an “immediate threat to health or safety for patients or the public” or do not comply with commission standards, according to its website. The decision is subject to further review and appeal before accreditation is formally revoked.

Fewer than 1% of hospitals nationwide were denied accreditation last year, officials said. Lansing’s other hospital, operated by McLaren, was last accredited by the commission in 2016 without any problems.

Jonathan Rohrer, associate dean at Michigan State University, labeled the commission’s accreditation as the “gold standard” for patient care.

Inspections basically look to answer two questions: Is the hospital doing the right things? Is it doing them well?

“We ultimately make an accreditation decision based on whether the organization successfully addressed identified deficiencies,” said commission spokeswoman Maureen Lyons. “In the overwhelming majority of cases, organizations come into compliance and improve within the required timeframe, usually 60 days after survey.”

A denial of accreditation is only a “last resort” for hospitals unwilling to resolve ongoing concerns, Lyons added.

The preliminary denial of accreditation is the first to be issued to Sparrow since at least 2011, which is far back as commission records show online. The Home Care and Laboratory departments in Lansing, which the commission also accredits, remain fully accredited without any cited areas of concern.


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Sparrow RN

Very misinformed and misleading article. Everything written is out of context. I am Proud to work at Sparrow and would recommend it to all the people that I love most.

Thursday, June 6, 2019
35 Year Sparrow Employee

The author of this article is ignorant. This article is TOTALLY misleading and taken WAY out of context. The author proceed to put a Hollywood spin on it, making it seem worse than it truly is. The author needs to put in an application to CNN . CNN is always looking for people to write, spin and peddle 'FAKE NEWS'

Thursday, June 6, 2019

Thank you for this article. Sparrow is one of three emergency residency programs that is not fully accredited by the Council on Graduate Medical Education. Sparrow is below the national average of identification of septic infections nationwide. I applaud that JCAHO made an unannounced visit to identify shortcomings in the provision of medical care at Sparrow. Identifying the problems provides an opportunity for correction. All of us in this community want good medical care at local hospitals. Indeed medical care along with education and public safety are the building blocks of all great communities. I trust that Sparrow will take up the challenge and address it deficiencies in a timely manner. All the beautiful buildings do not make a medical center.

I urge all residents to check out the JCAHO site to see the documentation of problems at Sparrow previous to this visit. This visit is just the most recent documentation of problems and is not a one incident situation.

We deserve better in the capital of Michigan.

Thursday, June 6, 2019
Eyes Without A Face

You Sparrow employees sound ridiculous with your comments. Just because YOU work there, doesn’t mean it’s immune from criticism.

The public has a right to know the truth about the inner-workings of their local hospitals. Stop being so offended. I am sure wonderful people work at Sparrow, but facts are facts.

Thursday, June 6, 2019
Insider eyes open

The lab DID fail through The Joint Commission...FYI. But are still Lab accredited.

Thursday, June 6, 2019
big dick

look out! here comes the nurses to bully you into thinking its all ok here.

Thursday, June 6, 2019

Sparrow Hospital killed a family member of mine. She went in for a procedure and should have been discharged the next day but instead there were complications and she acquired Hospital care acquired pneumonia and sepsis and died. Sorry Sparrow nurses but the truth hurts this Hospital is filthy and unorganized and a shitshow of commotion. They only care about making money.

Thursday, June 6, 2019
A hospital emplyoee non affilitated with Sparrow

I just love the comments made by people who never worked at a hospital or have been through a "unannounced" JCAHO inspection. Anyone working at a hospital who has been through a JCAHO knows all about it. Every time JCHAO comes through they have different inspectors and different agendas. It's not a consistent thing. One year they might come in you might get tagged because you don't have a enough soap dispensers in a certain hallway, a gurney might be in a hallway, a stain ceiling tile or a wheel chair was to close to a fire extinguisher, The yellow form should have been on top of the white form. Then the hospital gets tagged for it and people read it without knowing the REAL facts, makes assumptions, conclusions and sorry, plain ignorance because they believe everything they read. They think OMG! "WHAT A DISASTER!" "THE SKY IS FALLING" "My AUNTIE M DIED IN A HOSPITAL" (news flash, people do die in hospitals not because ). Let me tell you something, EVERY hospital JCAHO inspects finds something wrong with it. You're right, facts are facts but most of those facts can be VERY misleading but it doesn't mean the hospital is filthy unorganized or a shit show, how stupid. For the stupid comment that it's all about making money. If it wasn't for money hospitals would be closed. When was the last time you went to work and said you know what, I love my job it isn't about the money, you keep it.? How stupid

Friday, June 7, 2019

I am not an employee, this is just my true feelings from my own personal experience.... Since my car accident and surgery back in October and my husband having health issues and a few over night visits to sparrow since December we have had plenty of experience lately... We have had nothing but excellent service. The nurses have been so helpful and listen to the patients, they make sure that not only the patient is comfortable but also the family members. Yes, I know that not all of them are as wonderful as others, but I wouldn't want to go anywhere else. The Doctors listen to the patient's and want to set up a plan of care that the patient will agree with. Regardless of this article, we will continue to go to Sparrow!!!

Saturday, June 8, 2019

And I agree with "A hospital employee non affiliated with Sparrow".. People die every day at hospitals and that doesn't mean the hospital is to blame... Also, a lot of times (most of the time) it is the Doctor or surgeon that may have made the error NOT THE HOSPITAL!!! No hospital is 100% perfect. They do the best they can. I know that the family see's the mistakes and suddenly blames the hospital, however you do not see that chart and you don't see what is going on 24/7.

Again, I have always trusted Sparrow and no matter what this article says, I will continue to trust Sparrow and stand behind them 100%

Saturday, June 8, 2019

A hospital employee not affiliated with sparrow just so happens to know what the commission has really been looking at in sparrow this time. Hmm. Please dont lie about who you are. Your a bully a cheater and for paid by sparrow. When your best people leave and your left with the bottom half your not doing so well. There are a lot of secrets that would be appalling to the public of what is forced upon us by ignorant unexperienced management. Stop your fake rage at the freedom of press and social media and Stop calling people stupid and be a real leader. The voice of fear is a liar.

Saturday, June 8, 2019
Future Lansing Resident

Wow, seems like there is a lot of ill informed people. 1st, the Joint Commission always does their visits unannounced, this is nothing special. 2nd, every hospital will have violations. Joint Commission accreditation is always an ongoing process. (I also see an ignorant comment about CNN being fake news. Another targeting the nurses, even though most of the violations listed are physician based.) I shouldn't be surprised, the comment section is always a mess.

Tuesday, February 11

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