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Tenet's Palm Beach Gardens hospital continued to perform
high risk cardiac surgery over a five year period when there
were serious concerns about the risks of infection in its
operating theatres. Fixing these would have cut into profits
and the hospital would not have met its targets with the
theatres closed. Surgeons could have forced the matter by
refusing to operate but they continued to operate in spite
of the risks. Government oversight authorities and the JCAHO
could have forced them to fix the problems. They did not.
One hundred and six of those patients who died or developed
serious complications sued. They were awarded US $31
million.
The series:- Tenet and its
doctors
In July 2003 I wrote a web page titled "Tenet Health Care and its
doctors" which included the story of Tenet's relationship with its
doctors going back into the 1990s. In 2007 I put the material about
Redding hospital into a separate web page and wrote two more about
this revealing scandal within a scandal. The kickback allegations too
had become a major player in the wider scandal. This has also been
moved to a separate web page and updated. More Tenet sagas which
involve doctors have come to light and these throw additional light
on the many problems in Tenet's operations. While they deal with more
than just the doctors they all contribute to the story of doctors and
form a saga. I have therefore arranged them as a series called "Tenet
and its Doctors".
The web pages are
In Florida a hospital making huge profits from Cardiac surgery was alleged to have been lax and unwilling to devote funds to address serious problems that imposed a risk to patients. This occurred over a period of 5 years (1997 to 2002) between 1997 and 2002. Many died and others suffered serious complications that compromised their subsequent lives. The press has not debated whether the surgery in this hospital was indicated or not.
The impact of Tenet's focus on profit before care has become increasingly apparent with time. More and more evidence has emerged in regard to failures in care at Palm Beach Gardens. There are concerns about other operations in Florida. Tenet's manager in Florida was one of its old school. Dr Pearce and his dissident coalition of shareholders blamed this administrator for the money before care policies. They called for his resignation.
No action was taken by oversight authorities until 106 patients took to the courts and the press picked up the story. In spite of the serious systemic problems and a US $31 million settlement with patients, authorities allowed the hospital to continue caring for Medicare patients. The $323,800 fine was reduced by over one third. Information about the fine and findings were not released publicly - only after an FOI request.
It is important to remember that in the USA, even more than in Australia, health care companies spend vast sums on political lobbying and on campaign donations. There are close links between individuals in the two sectors. It is not revealed exactly what happened in this case.
Similar leniency by authorities is the rule rather than the exception.
It is worth emphasising that the alleged failures occurred prior to the scandal in October 2002, a time when the company was making vast profits. Those profits were coming from cardiac surgery.
In a situation like this the theatres should have been closed immediately and kept closed until the expensive repairs were carried out. Yet Tenet was unwilling to spend the money needed to fix the problems and provide adequate care. Profits would have fallen while the theatres were closed. Profit priorities prohibit this.
These events are reminiscent of the situation in some of Tenet/NME's psychiatric hospitals during the enormously profitable 1980s. Many hospitals were understaffed and staff were untrained. Patients were mistreated as costs were kept down and prices pushed up. Patients were denied care because the company would not refer profitable patients to another hospital when they were unable to provide it in house. One such was the Great Plains Hospital (5.15).
The doctors cannot escape blame. Cardiac surgery is high risk surgery and they could not have been unaware of the serious risks for their patients when insects landed on the operation. It was their duty to refuse to operate, to draw the situation to the attention of regulators and to enlist the support of their medical associations to have the issues addressed. This did not happen. The doctor's responsibilities and their names were not disclosed publicly in the press reports. They were not penalised.
In fairness to them they would probably have lost their jobs, and no other market focused hospital would have employed them. The company would have denied a problem and shifted the blame to them, even suing for defamation. At the very least they would have been so out of favour (called "out of the loop") that their incomes would have been seriously impacted. They had families, children at school and university, as well as large mortgages. They probably behaved like most others in their situation would have and developed ways to justify doing so. I have looked at how this works for management. Doctors can and sometimes will respond in the same way under the same pressures.
When a Dr Patel in a Queensland (Australian) government hospital was as reckless in the care given to his patients, the government hounded him across the world with charges of manslaughter. He carried out surgery for which he was not competent to please the hospital administrators who supported him.
Tenet eventually paid US $31 million in compensation to the 106 patients who sued because of the serious complications from cardiac surgery.
Tenet never acknowledged its culpability and continued to deny the allegations made even after hospital documents confirmed them and they had paid fines.
The reports in the press tell the story better than I can.
Oct 2002 When the Redding scandal explodes government finally acts
Federal health care officials are threatening to stop Palm Beach Gardens Medical Center from treating Medicare patients, who account for more than a third of its business, if ongoing infection-control problems aren't corrected in the next two weeks.
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"This is very, very serious."
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The U.S. Centers for Medicare and Medicaid Services said it found the hospital out of compliance with federal rules governing the hospital's infection control, quality assurance, physical environment and board of directors.
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The threat of losing the valuable Medicare patient business comes after state and federal regulators have inspected the 204-bed hospital at least three times since May. Health officials have received complaints about infection-control problems from patients.
In addition, the hospital faces 106 malpractice lawsuits from former patients and families of patients who claim that unsanitary conditions at the hospital caused infections following open-heart surgery.
Twenty of the lawsuits, all of which have been filed since 2000, involve deaths, said West Palm Beach attorney Calvin Warriner, who represents all the patients in litigation.
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In May, inspectors found that the hospital improperly stored surgical instruments and that some stretchers and intravenous pumps were dirty, according to a Florida Agency for Health Care Administration report obtained by The Post through the state's open-records law.
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But an Aug. 14 inspection found that Palm Beach Gardens Medical Center's food service also did not meet federal standards. Gardens hospital could lose Medicare certification Palm Beach Post October 25, 2002
Jul 2003 Law suits commenced
The first of more than 100 patients and survivors began suing Tenet's Palm Beach Gardens Medical Center in Florida, complaining of lax infection control and poor quality care. Ultimately, the federal government issued a rare "death threat," warning that it would halt Medicare and Medicaid payments if the hospital didn't clean up its act. Although the hospital escaped this sentence, frightening reminders of past conditions -- blamed for chest-rotting infections -- continue to surface as the pending litigation moves forward.
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- - - and attorney Cal Warriner -- who'd collected exterminator reports -- went on to proclaim that the hospital had bug zappers in the operating rooms, ant problems in the intensive care unit and flies breeding in the mop closets.
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"That's a disaster when you have a fly in the operating room," Rosen (a doctor whistle blower) said. "If it lands on the wound, that's an instant infection."Still, Rosen says the horror stories no longer surprise him.
"Based on what I know about Tenet," he said, "I wouldn't put anything past them."
Whistleblower Wants Tenet to Come Clean The Street.Com (Melissa Davis) Jul 25, 2003
Jul 2004 Flying insects in the theatres - costly to fix
But pest control documents, recently obtained by TheStreet.com, paint a chilling picture. For years, they show, Palm Beach Gardens struggled with -- but failed to correct -- an insect problem in its operating rooms. Correspondence between multiple exterminators and the hospital repeatedly mention, in some fashion, a "flying insect issue in the O.R." The exterminators identify specific insects -- crazy ants, fruit flies, fungus beetles, gnats -- and offer remedies to the problem. Their comments appear to grow more urgent as time goes on.
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By March of 2001 -- years after the problem erupted -- special consultants were clearly suggesting one of the most expensive remedies possible.
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... The ultimate solution is to open up the roof, remove all wet organic materials and replace the roof."
----------------------------
Just one month later, the long-time exterminators who hired the consultant found themselves terminated from the job. But a replacement firm sounded similarly troubled when it took over.
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But Sandra Perdew, the CFO of yet another firm, was still listing serious deficiencies the following year. She mentioned fly-infested mops and slime in the surgical trash room. She said the entire sterile processing room was "in poor condition and certainly in need of cleaning and maintenance." She said the general surgery unit had holes in the wall and cups of Pepsi on the trash can. She also mentioned concerns about the decontamination room and the nurses' lounge. - - - - - - "The maintenance and structural issues (in the food area) that we went over ... remain the same," she wrote in February 2002. "It is imperative that we work together to get this problem under control."
Florida Heart Surgery Law Bugs Tenet Healthcare The Street.com (Melissa Davis) July 6, 2004
Jul 2004 A paltry fine for a shocking situation
Palm Beach Gardens Medical Center paid a $95,000 fine to the state for ignoring rampant infection-control problems, improperly storing medicine and failing to alert health officials when patients were unexpectedly returned to surgery with postoperative infections, according to documents obtained Wednesday by The Palm Beach Post.
--------------------------
In March of last year health officials actually levied a $323,800 fine against Palm Beach Gardens Medical Center - the largest fine ever assessed by the state - but they accepted the lesser payment. Officials on Wednesday had no answer to why a much smaller penalty was accepted from the hospital.
----------------------------
In a 55-page complaint, state health officials painted a detailed picture of a dirty hospital that left dust and dried blood on medical equipment and stretchers and neglected to deal with infections that forced patients to undergo additional surgery.State logged problems
State health officials uncovered many problems at Palm Beach Gardens Medical Center during inspections in 2002:
- The hospital failed to submit adverse incident reports to the state in 13 of 24 surgical cases reviewed. The hospital was required to tell the state within 15 days after patients were unexpectedly returned to surgery with infections.
- The facility did not attempt to identify the cause of the postoperative infections.
- The hospital left medications such as heparin and nitroglycerin tablets in the hallways and unlocked storage rooms.
- Thirteen of 24 sampled surgical patient records reviewed in May 2002 showed massive postoperative infections requiring patients to experience extended hospital stays and return to surgery for reconstructive repairs to surgical wounds.
- Sterile materials were stored with unsterile materials.
- Intravenous pumps had splashes of dried substances on them.
- Dust and grit were found under recovery room stretchers.
- Wheels on recovery room beds had dust and a dark brownish material on them.
- The only corridor from the operating room and cardiac catheterization lab to intensive care units was through a construction area. Staff and visitors would track dust and dirt from this hallway into the units.
- The hospital did not maintain proper ventilation to make sure sterile rooms were not exposed to unsterile air.
- Overflowing carts with soiled linen were left in hallways.
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"Postoperative infections were not timely identified and patients were discharged with elevated white blood counts to return a few days later with fever, sepsis and surgical wound infections," according to the complaint. "The facility was not maintained to ensure the health and safety of patients, staff and visitors."Despite the hefty penalty and the public health issues involved, the Agency for Health Care Administration did not announce the fine to Florida residents.
--------------------------
"If you don't announce these things loudly and clearly, you are failing your responsibility to the patients of Florida," Wolfe (doctor critic) said.
Gardens hospital paid $95,000 fine for infections: The fine, believed to be the largest a hospital has paid the state, wasn't publicized. Palm Beach Post July 21, 2004
Dec 2004 Tenet settles court action
Hospital operator Tenet Healthcare Corp. on Thursday said it has agreed to settle 106 individual lawsuits filed against its Palm Beach Gardens Medical Center that claimed patients had suffered post-surgical infections after having cardiac surgeries. Tenet agreed to pay $31 million to the plaintiffs and their lawyers.
Tenet Settles Lawsuits in Fla for $31 Mln Reuters December 23, 2004
G M Gaul writing in the Washington Post on July 24, 2005 used Palm Beach Gardens to illustrate the way in which the Medicare system rewards poor care and penalises good care. The hospitals are paid more when things go wrong and they have to treat complications.
With the best of care complications and failures do occur. In a normal civil society where community services serve citizens and are driven by non-commercial motivation it is only reasonable that those who provide care should not be penalised when complications occur, and should still be paid. The marketplace turns all this fairness on its head.
This is because managers and investors think very differently. They expect a return on money and effort invested in the business, whether this is in equipment, training, or staff. Investment in these is an increased cost without any return. As Gaul indicates profitability is reduced when there are fewer complications. Outcomes are measured commercially and not in terms of quality of care, although these feature prominently in corporate marketing.
In 1993 I discussed these issues with a Tenet/NME US administrator who had turned whistle blower in 1991. He helped to expose the first scandal. His explanation was concise "that's the way they think". Elsewhere I have tried to explain (pdf file) at greater length why and how this happens. It results in a chasm between the way the market sees medicine and what the community expects of it.
In a marketplace context there are no commercial incentives to improve and without monetary incentives the market does not respond. They don't invest money in something if there is no return on the investment. Managers are trained to think in this way. Values and humanitarian motives are the victims of market thinking.
Documents from Tenet/NME's 1991 scandal revealed that quality was measured in terms of profitability not care. If a service was very profitable (even by overcharging Medicare) then it followed logically that that the service is of high quality. If not patients would not pay! It is likely that Tenet's logic like its business policies has not changed.
Jul 2005 Poor care with major complications is more profitable
In a four-year period, 106 heart patients at Palm Beach Gardens developed infections after surgery, according to lawsuits and government records. More than two dozen were readmitted with fevers, pneumonia and serious blood infections. The lawsuits included 16 patients who died.
How did Medicare, the federal health insurance program for the elderly, respond?It paid Palm Beach Gardens more.
Under Medicare's rules, each time a patient comes back for another treatment, a hospital qualifies for an additional payment. In effect, Palm Beach Gardens was paid a bonus for its mistakes.
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In Medicare's upside-down reimbursement system, hospitals and doctors who order unnecessary tests, provide poor care or even injure patients often receive higher payments than those who provide efficient, high-quality medicine.
--------------------------
There may be no starker illustration of Medicare's upside-down economics than Palm Beach Gardens Medical Center, a 204-bed hospital on Florida's east coast. The hospital, part of the Tenet Healthcare Corp. chain, boasted one of the busiest cardiac programs in South Florida in the 1990s, performing more than 1,000 open-heart operations annually.
-------------------------
Some patients had to have additional operations or return multiple times to the hospital as a result of infections, according to state and federal records obtained under the Freedom of Information Act.
----------------------------
The warning to Palm Beach Gardens proved to be no different. Medicare never cut off the hospital's payments. After the hospital filed a "plan of correction," it was back in Medicare's good graces.State regulators did fine Palm Beach Gardens -- $323,800 in March 2003. But they quickly reduced it to $95,000. Elizabeth Dudek, Florida's top health regulator, said they did so "to avoid what could be a costly and lengthy appeal."
Hospital officials agreed to the fine without acknowledging any wrongdoing.
------------------------
In 2004, Tenet settled more than 100 civil lawsuits for $31 million, again without admitting wrongdoing. After suffering a drop-off in business, Palm Beach Gardens is once again busy. The hospital's Web site touts its heart program as among the nation's best.
CHRONIC CONDITION The Waste in Medicare Spending: Bad Practices Net Hospitals More Money: High Quality Often Loses Out In the 40-Year-Old Program Washington Post (G M Gaul) July 24, 2005
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