By Anne Blythe
It’s unclear how long a state health department team will take to investigate questions raised in The New York Times about pediatric heart surgeries performed at the North Carolina Children’s Hospital in Chapel Hill.
State regulators were at the UNC Medical Center on Monday as part of an inquiry launched last week by Mandy Cohen, secretary of the state Department of Health and Human Services.
On May 30, The New York Times published an investigative piece by Ellen Gabler spotlighting high death rates in 2016 and 2017 in the pediatric heart surgery program that so troubled pediatric cardiologists in the department they questioned whether to send their own patients or children there.
As part of their report, the Times obtained secret audio recorded from meetings in 2016 and 2017 in which cardiologists pressed their division chief for answers.
At one meeting, according to the Times, Blair Robinson, a pediatric cardiologist at WakeMed, said: “I ask myself, ‘Would I have my children have surgery here?’ In the past, I’d always felt like the answer was ‘yes’ for something simple. …
“But now when I look myself in the mirror, and what’s gone on the past month, I can’t say that. And if I can’t say it for my kids — and that should be our group discussion — if we can’t all look ourselves in the mirror and think we’re doing the right thing, then we need to change what we’re doing.”
The Times sought risk-adjusted mortality data for the pediatric heart surgeries done on young children with congenital heart defects, statistics that 74 percent of hospitals performing such surgeries report on a Society of Thoracic Surgeons website.
But UNC Health Care did not provide that information, the Times filed a lawsuit in state court seeking the records.
‘Conduct a thorough investigation’
Cohen announced late last week that she had assembled a team from the state Division of Health Service Regulation, which licenses and oversees health care facilities, to “conduct a thorough investigation into these events.” They are coordinating with the U.S. Centers for Medicare & Medicaid Services, a federal oversight agency.
“As a mother and a doctor my heart goes out to any family that loses a child,” Cohen said in a statement released May 31. “Patient safety, particularly for the most vulnerable children, is paramount.”
Cohen said in her statement she could not discuss any ongoing investigation.
Kelly Haight Connor, a spokeswoman for the state health department, said Monday it’s difficult to know how long an investigation will take. In other DHHS investigations, a team often interviews a range of people, from caregivers, staff and those in their care.
Wesley Burks, CEO of UNC Health Care since December 2018 and dean of the UNC School of Medicine, sent a five-paragraph email to staff on May 30 at 10:16 a.m. and attached the Times’ article he described as “critical of UNC Medical Center’s pediatric congenital heart surgery program.”
“While this program faced culture challenges in the 2016-2017 timeframe, we believe the Times’ criticism is overstated and does not consider the quality improvements we’ve made within this program over many years,” Burks wrote in the email. “As the State’s leading public hospital, UNC Medical Center often gets the most complex and serious cases in its pediatric congenital heart program. For many of these very sick children, we are often parents’ last hope.
“Recognizing that the loss of one child is too many, a number of quality improvement measures were implemented over many years.” Burks continued. “In fact, as you know from your own areas, we will forever work on continuous quality improvement (CQI) efforts. In addition to process changes, hospital leadership determined that certain personnel changes were required to improve the culture and new physicians and staff were recruited. All of these efforts have led to improvements in the program’s outcomes.
“UNC Health Care is dedicated to continuous improvement of our programs and the medical outcomes they produce,” Burks said. “We’ve invested significant time and resources in our pediatric congenital heart surgery program and will continue to do so in the future. We are proud of the pediatric congenital heart surgery program, and our team is currently receiving top results that would place us among the best in the nation.”
Melina Kibbe, chair of the UNC department of surgery since July 2016, and Stephanie Duggins Davis, chair of the UNC Department of Pediatrics and physician in chief at NC Children’s Hospital since July 2018, also wrote a response to the Times’ article in an opinion piece published by The News & Observer.
They, too, mentioned “cultural challenges related to personality conflicts and difficult group dynamics” during 2016 and 2017 and noted the turnover and new leadership since then.
On Monday, UNC Health Care spokesman Phil Bridges released a “timeline of Continuous Quality Improvement within the program over the past 10 years.”
The timeline mentions a four-month period from June to September in 2016 in which “concerns and allegations against specific individuals in the Congenital Heart Program” were “independently investigated and reviewed” by the dean’s office and the chief medical officer.
“Allegations of misconduct and concerns determined to be unfounded,” the document states, adding “allegations against specific individuals and results of the investigations constitute personnel records, which may not be disclosed,” citing public records law.
An ongoing initiative, according to the document, calls for a Department of Pediatrics review after every death in the Pediatric Intensive Care Unit, including pediatric cardiac patients, to assess the care provided and evaluate any opportunities for improvement.
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Working at UNC Health Care in strategic planning and development, I can all but guarantee the administration has seen the data that shows how dangerous their peds cardiac surgery program was. The physicians probably weren’t shown to give them plausible deniability and they have every reason to be angry. This kind of reckless and arrogant attitude is endemic to the senior leaders of UNCHC.
As a state-owned hospital system, accountability is not a priority because the administration of UNCHC knows they will never be held accountable by the very legislators that pay their exorbitant salaries. Though they claim to be a safety net hospital their leadership in no way reflects their patients or providers demographically. While every major health system in NC has diversified their administrative teams and brought in responsible, values-driven leaders, UNCHC has consciously chosen to retain a calcified leadership team that prizes groupthink and non-transparency. This story exposes just how dangerous the consequences of such a culture can be.
It’s telling that the physicians who spoke up in these meetings are gone. Though some left on their own, the others were pushed out like many others at UNCHC who challenged unethical behavior. It’s also telling that the person who recorded these meetings felt the need to do it anonymously and secretly. Our tax dollars pay the administration of UNCHC. Let that sink in for a minute.
I live in Charlotte. Don’t think accountability is any better here. NC is out of control when it comes to errors. Plenty of our citizens are posting stories in Medical Error Transparency Plan, Mothers Against Medical Errors, Patient Safety Action Network, medication, device and specific surgical groups (sigh). I definitely admire all the providers and patients who now record to get transparency. Also, there are now many closed provider groups where people are sharing systemic weaknesses. UNC is simply not alone, sadly.
What is the probability that NYT got its info from trial lawyers?
I’d say almost zero. Something tells me most health systems aren’t in the habit of inviting outside lawyers to physician staff meetings, much less lawyers who might record them (secretly or otherwise).
The simpler (and much more likely) explanation’s that a provider saw the gross systemic negligence resulting in deaths, couldn’t square that with their ethical duty to do no harm, and took it upon themselves to bring this to light.
Regardless of who brought the information forward, the fact of the matter is that young children were dying at a rate double that of the average pediatric surg program. This is not the work of single surgeon, there are many, many parts to a process as complex as heart surgery.
The real question is: how did this happen for so long, and who will be held accountable?
To say that our public, state-funded flagship health system didn’t compile and evaluate the data after multiple deaths defies belief. An unexpected pediatric death is a sentinel event. If UNCHC’s administration weren’t evaluating this program after the second death, then that’s negligent to the point of criminality. Our own physicians wouldn’t send their kids there!
You do know that NC is one of the states where families who experience preventable adverse events are least likely in the nation to get compensation, right? Check out the NPDB numbers.
JR–thanks for your perspective!
Anne Blythe, why is it that only the male doctors deserve the honorific? The women department chairs are doctors, but are only referenced by their names?? you should fix this.
That was a copyediting error that we’ve fixed, thanks for pointing it out. We usually don’t use the honorific of “Dr.” for any physician, especially because we usually go on to identify them as “pediatrician” or “cardiologist” (which are doctors, right).
Since NC became tort reform, the state has been described as “out of control” with medical errors, and while electronic healthcare records used to be quite accurate, that isn’t the case anymore. Malpractice attorneys have left the state, switched to personal injury, and those that are left may see over 150 cases and take one, but they often toss the pediatric cases, as simply not worth it. Since settlements have pretty much stopped, cases will be in court 3 to 5 years and families are far more likely to pay for harm than to even get an apology. NPDB numbers show that NC is at the bottom of the barrel for compensation following harm. Families routinely do their own root cause analysis following harm, as both the EHRs and death certificates leave lots to be desired. Recording has become pretty common. I know a parent who was given advice on how to record to capture problems, and the info came from someone in law enforcement. https://www.youtube.com/watch?v=QuOBmQwPSHA&feature=youtu.be
I tip my hat to the UNC employee who risked retribution to improve care for kids! Reminds me of NC provider Donna Helen Crisp, a medical ethics instructor, who wrote about her preventable adverse event in a medical facility and spoke nationally (see Amazon’s Patient in Room 2). Like Donna, I’ve spoken about a NC poor family outcome (YouTube HealthWatchUSA Emily Paterson). Others like Amanda Rusmisell (with medical device groups) and Rachel Brummert (with medication groups and a CDC representative) share stories too. While many of us are sharing or even recording, it saddens me that scientific root cause analysis seems lacking & both providers and patients appear to be attempting to creatively improve transparency in unusual ways. Meanwhile, I’ve heard that reputation repair companies are doing good business in NC, and they aren’t shy about their goals (see YouTube Social Clime Dr Mitch for a 2 minute ad which reminds one of Saturday Night LIve).
The Charlotte program to has had its challenges and still does not have high marks. Place had hired and fired several peds CV surgeons and allowed some to only do adults. Someone should also take a look at heart and liver transplant survival rates in NC.