Sparrow: Safety concerns ‘resolved’

Officials at Sparrow Health System maintain that more than 90 deficiencies uncovered in a recent safety inspection were “entirely resolved” in recent weeks. But many details about the problems (and their fixes) remain unknown.

Dr. Karen Kent VanGorder, senior vice president and chief medical and quality officer at Sparrow, expects the accrediting organization The Joint Commission to overturn a preliminary denial of accreditation issued in April for scores of safety citations at Sparrow Hospital in Lansing. But, like other officials, she refused to shed much light on the findings.

“Patients should be completely reassured that we have been thoroughly inspected and vetted and that we pass even the most rigorous investigations, repeatedly,” VanGorder told City Pulse.

The Joint Commission is an independent nonprofit that inspects and accredits about 80% of U.S. hospitals on a series of safety measures. It issued a preliminary denial of accreditation — a prerequisite to the acceptance of Medicare and Medicaid payments — on April 20, one day after a weeklong, surprise inspection at the hospital.

The commission issues a preliminary denial when hospitals either create an “immediate threat to health or safety of patients or the public,” or do not comply with commission standards, according to its website. Fewer than 1% of hospitals nationwide were denied accreditation last year. The preliminary denial was a first for Sparrow, VanGorder said.

VanGorder and other officials have repeatedly declined to elaborate on the vast majority of concerns identified in the commission’s May 24 report, including citations for incomplete operative notes, unlocked anesthesia carts, improper medication labeling, inadequate identification of patients at risk of suicide and numerous other issues.

Those concerns, however, have since been fixed, VanGorder said.

“It’s important to notice these are all potential problems and not actual problems. No patient care was affected by any of these things,” VanGorder said. “You could potentially say we’re completely in compliance” with Joint Commission standards. “We’re in constant contact with TJC. They have reassured us that it’s taken care of.”

A review for a final determination is under way. The hospital, in the meantime, remains accredited. Online reports (supposedly pegged for revisions later this summer) still list at least 48 non-compliant safety standards at the hospital, but VanGorder said the latest round of inspections failed to identify a single area of concern.

A spokeswoman for The Joint Commission declined to confirm any recent developments, communication with the hospital or elaborate on any anticipated changes to Sparrow’s accreditation status. She pointed to online records and also declined to elaborate about any of the citations based on  “the privacy of all involved.”

“The absence of findings is a good thing,” VanGorder said. “Those would have been given to us in writing.”

Recent citations included: The competence of staff to perform their responsibilities; infection prevention; fire protection; education about followup care and treatment and concerns about “time-outs” — the final check by medical personnel before a procedure on whether they have the right patient and fully understand the operation.

VanGorder wasn’t exactly sure what led to Sparrow’s first preliminary denial from the commission but insisted that one-third of the reported citations were immediately corrected during the inspection. And while some citations may seem alarming, many had no direct link to patient care or treatment, VanGorder said.

Infection prevention citations were tied to staff washing their hands in the wrong sinks, VanGorder said. A stretcher parked near a hospital doorway also dinged Sparrow for adequate fire prevention, she said. As for the competence of staff? That came down to an administrative snag based on improperly filed paperwork, she said.

“You don’t wash your dirty shoes where your wife is making a salad.  It’s that kind of thing,” VanGorder added. “We also have to transport instruments from one place to another in complete compliance with fastidious rules.”

Other broad citations found in the commission’s report included deficiencies in patient planning and assessment, safe and effective treatment, the management of hazardous medication and waste, the existence of safety and security risks and poor maintenance of “complete and accurate” medical records for each patient.

VanGorder declined to address those issues, instead pointing to other, perhaps lower priority, concerns.

“All of the findings are important. It would be hard to say that one thing is more troublesome than another,” VanGorder said. “It’s like potholes in the street. If you don’t drive into them, then there’s no real problem. In this case, we went back in and validated that nobody drove in these potholes and they were all repaired.”

So, despite supposed fixes over the last few weeks, how did these deficiencies materialize? VanGorder said she and the hospital received written documentation for every commission concern. She’s just not sharing the details.

“You’d have to ask the Joint Commission,” VanGorder added.  “Why this one led to that? I couldn’t tell you.”

The Joint Commission spokeswoman said most hospitals come into compliance and improve after a preliminary denial is issued — usually within 60 days of the initial survey. A denial of accreditation is only a “last resort” for hospitals that are unwilling to resolve ongoing concerns. VanGorder doesn’t consider that a possibility.

“If I’m in the community, I’m not excited that 90 things were found,” VanGorder added.

“But I think if you have an organization that does what we do on a daily basis — and does it in as many places as we do it — you’d want to know that someone is shining a light in our corner. That’s what this report does for us.”

City Pulse first publicized the Joint Commission report earlier this month after a source (who asked not to be named) provided a copy of an internal staff email regarding the citations. Officials previously declined an interview and issued a one-paragraph statement that noted: “all concerns have been corrected and cleared.”

After a story published last week on the topic, more than 500 copies of City Pulse went missing from Sparrow Health System facilities after they were delivered. A hospital front-desk staffer said the papers were removed because of a “negative” story. VanGorder and Vice President Illene Cantor denied any knowledge of their disappearance.

“I don’t have any information on that,” Cantor added.