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:
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:
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.