State regulators swooped down on Central DuPage Hospital in Winfield last month to investigate why seven patients had been operated on with instruments that had not been properly sterilized.
It was the latest in a series of unannounced inspections that uncovered various problems in the hospital. The federal government, prompted by what regulators discovered, ordered another top-to-bottom survey of the hospital, which has yet to be conducted.
Last fall, four of the hospital’s key executives, including the president and the chief executive officer of Central DuPage Health, the corporate parent, resigned, offering little explanation.
David Brooks, interim co-chief executive officer of Central DuPage Health, said it has been “stressful” for some staff members whose bosses left, but he maintained the hospital is delivering excellent care and is in good financial shape.
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“We’ve got great doctors, great training, great providers,” Brooks said.
Still, the inspections and exodus of top leaders show how a hospital, if it isn’t vigilant, can encounter problems in the complex task of delivering health care.
Hospitals and other medical facilities undergo routine inspections by state officials and usually infractions are minor. Verifying complaints about incidents such as the incomplete sterilization of surgical instruments is rare and serious, industry officials said.
“It’s a patient-safety issue,” said Steven Scheer, a principal with Health Management Associates, a Chicago health-care consulting firm.
The key is to quickly correct problems, small and large.
“If they continued to have [sterilization problems], that’s how you go from being a good hospital to a bad hospital,” he said.
Central DuPage officials insist none of the seven patients involved in the Oct. 9 and 10 sterilization incident was harmed and procedures have been changed to prevent a similar event.
But the incident was serious enough that hospital authorities reported it to regulators and considered shutting down the operating room. It also prompted an anonymous complaint to federal regulators, who sent state authorities to the hospital Feb. 13 and 14. It was their fifth visit in 12 months.
Information gleaned from dozens of interviews with hospital personnel and from federal and state documents show the last year has been difficult for the 361-bed hospital and its staff.
A year ago, the hospital scored in the bottom quadrant of hospitals nationwide in its triennial accreditation survey. In April, state inspectors verified that in 2000 a woman had nursed the wrong baby, a finding that prompted the federal government to order the first-ever full survey of the facility and threaten to drop it from the Medicare program. The subsequent inspection found widespread problems. Days after state regulators determined the deficiencies had been corrected, the sterilization incident occurred.
A few weeks later, David Fox, hospital president, resigned. Then, in late November, Donald Sibery, chief executive officer of Central DuPage Health, quit.
Since then, an interim team has been assembled and a national search is under way to find a chief executive officer.
A new direction
Since its founding in 1964, the hospital has become the fifth busiest surgical center in Illinois, the busiest emergency department in DuPage County and the first hospital in the county to perform open-heart surgery.
In 1996, Sibery, who was president and chief executive of Community Health Care Inc. in Wausau, Wis., became chief executive officer of Central DuPage Health. He came with an aggressive vision that included “growing” Central DuPage Health, the health-care network that includes the hospital.
In February 2002, Central DuPage scored an 87 on its accreditation, placing it in the bottom 22 percent of hospitals nationally, according to the Joint Commission on Accreditation of Healthcare Organizations, an influential private inspector of hospitals based in Oakbrook Terrace.
“Anything in the 80s is eye-opening,” said David Dranove, professor of health industry management at Northwestern University. “You can lose points for just doing an inconsistent job of recordkeeping, so a low score is not always indicative of poor quality, but it’s something you want to look at.”
At Central DuPage, one of the biggest problems was medication use, though the Joint Commission would not release details. Other problems arose in areas such as initial patient assessments, assessing staff competence and availability of patient data, according to the Joint Commission.
Brooks, noting the hospital is fully accredited, said many of the problems were related to improving the documenting of care. The hospital submitted additional information and earned an updated score of 94 in September, according to the Joint Commission.
In the last six years, other area health-care facilities received scores in the 80s, only to have them updated to the 90s. But at Central DuPage, the Joint Commission visit marked only the beginning of outside scrutiny.
In April, state regulators investigated three complaints, verifying one.
In that instance, which occurred in September 2000, a woman nursed a newborn girl who was not hers.
The infant’s mother had been moved to another room, but her daughter’s bassinet card was not changed, said Dr. Robert Chase, a hospital medical director and expert on infectious disease.
Staff mistakenly thought the baby’s and the mother’s identification tags matched, because every digitwas identical except the last one.
Chase and Brooks said extra measures were implemented to prevent a similar incident and there has been no reoccurrence.
Medicare threatens
That incident and others were serious enough that the federal Centers for Medicare & Medicaid Services’ Chicago office notified the hospital it did not meet conditions to participate in the Medicare program. The state Health Department would conduct a full survey.
Such a survey is relatively rare, according to Bob Daly, a Centers for Medicare & Medicaid Services manager in Chicago. Of the 137 Illinois hospitals eligible for such a review, nine were surveyed in 2002, including six in the Chicago area.
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At Central DuPage, inspectors arrived unannounced in late July and found enough in three days to fill a 35-page report. Violations included improperly cleaned operating rooms, outdated drugs, refrigerators kept at improper temperatures and pans of moldy food in kitchen ovens.
Inspectors also cited the hospital for an incident in which two premature newborns tested positive for an antibiotic-resistant germ. Of the 17 people who had contact with the babies, five had not been screened to see whether they carried the drug-resistant germ, according to federal documents.
Chase said the employees were either on vacation or off-rotation, and each was screened before returning to work. All tested negative, he said.
As the hospital corrected the problems, two senior executives resigned in September: Barbara Lockwood, vice president of patient care, and Dr. Vincent Sackett, vice president of medical administration.
Lockwood said her departure was a mutual decision. Sackett said he no longer agreed with the organization’s culture.
“It’s a better fit for some people than it is for others [and] for me it wasn’t a good fit anymore,” Sackett said.
The state returned in October and found all but a few problems had been fixed. Yet a few days later, hospital officials discovered that some surgical instruments were not properly sterilized, undergoing only two steps of a three-step process, Chase said.
Brooks said the process has been improved.
Eleven days later, Fox resigned. He has declined to discuss his departure, but Brooks said it was not connected to the sterilization incident.
Fox’s exit unsettled some staff. In subsequent weeks, some medical staff pushed to have Fox reinstated, but it never happened, and, about a month later, Sibery resigned.
Sibery declined to comment, but Bradley Kinsey, Central DuPage Health chairman, said Sibery told him “organizations go through cycles where they need different leadership.”
The corporate board hopes to select a chief executive officer by spring, Brooks said.
“Again, it’s unfortunate that at times human error occurs in health care, even though [Central DuPage] is committed to providing the best and safest care always,” Brooks said.