King/Drew’s 1,000 Failings

The “culture of excuses and blaming” at Martin Luther King Jr./Drew Medical Center is so deeply ingrained that fixing the troubled public hospital probably will take much longer than a year and cost much more than the millions of dollars Los Angeles County has committed to the effort so far, officials said Monday.

Just getting King/Drew “back to an average American hospital” will take at least a couple of years, said Dr. Thomas Garthwaite, director of the county Department of Health Services.

His assessment came as the consultants hired to turn around the hospital issued their first evaluation of King/Drew -- a lengthy report that lists nearly 1,000 recommendations for change.

Some of the proposals by Navigant Consulting, which has a one-year, $13.2-million contract at King/Drew, addressed basic medical failings by the hospital’s staff. Those failings persist despite months of scrutiny by regulators, the health department and the media.

In detailing how those problems have continued, the report implicitly criticizes the county health department, which directly managed King/Drew from December 2003 until Navigant arrived in November.

The consultants explicitly suggested that the problems would not get better so long as the Board of Supervisors continues to be in charge.

“At minimum and immediately, a separate, independent and knowledgeable board” should be appointed to oversee the hospital, the consultants suggested.

Over the longer term, they said, a separate hospital authority should be created -- a system in use in some other metropolitan areas to try to shield hospitals from political interference. Los Angeles County supervisors have shown little interest in such an independent board in the past.

Regardless of who has ultimate authority, the consultants’ report indicated how difficult the process of fixing the hospital will be. In the psychiatry department, for example, “all staff need to be reevaluated for competency,” the report states.

The report stressed the problems caused by what the consultants referred to as King/Drew’s “culture,” in which management has not insisted on accountability and staff members have not always taken responsibility for doing their jobs properly.

After briefings by Navigant officials Monday, several supervisors said that changing the hospital’s culture probably will mean firing staff, even if they are veteran doctors with strong community ties.

“You can’t just paint a room and have everything be comfortable and have the same incompetent staff,” said Supervisor Don Knabe. “This has to be outright firings.”

Many of the report’s findings echo those documented in a five-day series of stories published by The Times last month. A team of reporters spent a year examining the hospital and found that errors and neglect at the facility, in Willowbrook just south of Watts, had repeatedly injured or killed patients for more than a decade.

Like The Times, Navigant found crucial departments in disarray, inadequate performance reviews of physicians and an ineffective disciplinary system. Some areas of the hospital remain battered and sorely in need of repair. Surgical staff, for example, still do not consistently don masks or sterilize operating room instruments, the report states.

Some staff were unable to competently respond to a “Code Blue” emergency call, the report states. They either never showed up or didn’t know what to do when they arrived.

Navigant also found:

* Physicians were not always available in the emergency room, many nurses lacked proper credentials, and equipment that monitors the vital signs of patients often broke down.

“Night shift staff are sleeping during their shift, and staff on all shifts are known to disappear,” the report added.

* Operating room staff failed to routinely ensure sponges and other instruments were removed from patients. Sterile and nonsterile equipment were mixed together in storage areas.

Several students from healthcare training programs were observed lingering in operating rooms without managers being able to identify who they were, what they were doing there or who was supposed to be overseeing them.

* Patient rooms in the psychiatric units were deemed unsafe despite efforts to remodel them. In some cases, the report said, “doors to closets are removable and ... can be used as weapons.”

Official records listed compliance with hospital regulations “at 100%, which seems unbelievable after observing actual practice and preliminary interviews with staff,” the report noted.

* There is no process for reporting unusual deaths of patients and analyzing whether doctors or nurses made mistakes that contributed to those deaths. Nurses often did not report medication errors, the report states.

Navigant was hired at the insistence of federal health inspectors. Its report, which will not be final until Feb. 1, is meant to provide a road map for how the consultants hope to turn around the hospital. Once the report is final, Navigant and county officials will be making decisions over the next 30 days on how to proceed.

In the meantime, the hospital faces several possible crises. Most crucially, it soon could lose the $200 million it receives annually in federal Medicare and Medicaid reimbursement. Federal officials have threatened to cut off the money because of the hospital’s failure to curb the use of Taser stun guns on patients, especially in the psychiatric unit.

Federal officials are scheduled to decide in the next several weeks whether to stop payments, a step that county officials have said probably would force them to close the hospital.

Some of Navigant’s findings appear to point to additional violations of state and federal health regulations. Those findings could trigger a fresh round of inspections.

After being briefed on the report, some county supervisors questioned whether substantive changes could be made with the current staff in place -- or whether the consultants’ recommendations could be implemented.

“That’s going to be where the rubber meets the road,” said Supervisor Zev Yaroslavsky. “If we can’t turn around this hospital with this road map, it can’t be fixed.”

In the past, the consultants said, instead of complying with hospital policies, King/Drew staff members changed policies to accommodate their habits. For example, under pressure to start surgeries on time, staff members simply began listing the time the patient entered the operating room.

“Unfortunately, the surgical team has not prepared the room prior to the patient entering,” the report states.

As a result, the report states, patients often lingered until surgeons began to operate.

One of the biggest hurdles to King/Drew’s improvement remains its inability to evaluate, train and discipline its employees, the report states.

King/Drew’s human resources department was “largely dysfunctional for about seven years, creating significant problems, which are now being addressed,” the consultants found. Currently 8% of the staff of nearly 2,500 has a workers’ compensation claim.

Navigant recommended hiring a senior human resources person for the hospital and reviewing all existing workers’ compensation claims.

The report also recommends proposals fought by hospital supporters in the past, such as downgrading the neonatal intensive care unit to focus on babies who are less sick and possibly reducing the number of physician training programs at the center.

Though the report clearly suggests that many physicians and nurses need to be retrained or removed, it also suggests keeping on some physicians who have served in leadership roles.

For example, in the neurosciences department, the report notes that “department leadership is nearing retirement” and there are no plans for a successor.

“Emeritus status may be considered to retain the contributions of and prestige associated with the current leadership,” the report states.

The report did not name the current leadership. The current chief of the department is Dr. George Locke, 70. The Times investigation detailed questions about his work schedule and the number of surgeries he performed. Locke earned more than $1 million over the last two fiscal years.

When asked about the emeritus proposal, Navigant director Kae Robertson said the leader referred to was not Locke. She would not say whom the report referred to, and noted that the report was not final.

Supervisor Mike Antonovich said the proposal would not be acceptable. “We’re adamant that no incompetent and failed medical professional is going to be excused with some honorary title,” he said.

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Problems, possible solutions

Monday’s lengthy report by Navigant Consulting cited the following problems at Martin Luther King Jr./Drew Medical Center and some potential solutions:

“Numerous issues exist in pharmacy, including the lack of full-time, dedicated management ... and a plan to implement information systems that is too prolonged. Despite prior problems with drug diversion, there is still a need for improving drug security, including installation of security cameras and changes in policies/ procedures.”

* “Quality of care is not built into the fundamental processes of taking ‘care’ of patients.... Patient satisfaction has not been measured since the first quarter of 2003.”

* “It is critical for the Board [of Supervisors] and hospital to be able to hold the medical staff accountable for the clinical time and coverage that it is financially supporting. There are reports of clinical situations where physician oversight is needed but not available.”

* “The sum of residency program requirements exceeds the clinical breadth of patients available at [King/Drew].... There needs to be a review of each residency program to determine if it should continue to stand alone, be integrated with another program or eliminated.”

* “The overall physical condition of the mental health area is substandard and subject to serious censure by any authority ... that should inspect the area.”

* “There were numerous patient safety violations including: basic OR principles not being followed, such as sterile field maintenance and wearing masks; instrument, sponge and sharp counts inconsistently performed; site verification not routinely checked or documented; and inconsistent instrument cleaning.”

* “Values need to be developed and internalized.”

Source: Navigant Consulting

Los Angeles Times