TAMPA, Fla. _ A federal investigation into Johns Hopkins All Children's Hospital in St. Petersburg found failures in oversight that went far beyond the hospital's Heart Institute.
A report released Friday criticized the basic nature of the hospital's structure, where virtually all authority rested with a few Johns Hopkins executives. It rebuked the hospital's board of trustees for not exercising proper oversight. And it detailed systemic problems with infection control.
All Children's had been required to submit a plan for addressing the issues earlier this month. On Friday, All Children's said the federal government had accepted its plan and the hospital was no longer at risk of losing public funding.
Hospital leaders called the development "good news," but said it was "by no means the end of this important process."
"We take the issues raised by our regulators very seriously and will continue to collaborate closely with them as we implement our plan," the hospital said in a statement. "We must be vigilant and diligent every day and, most importantly, we cannot forget what happened here and what we have learned."
The federal report found that All Children's did not collect or track individual physicians' outcomes and had no system for analyzing "data used to monitor the overall quality of care and patient safety provided by the hospital."
In addition to the federal government's main findings, All Children's was also cited for several smaller infractions, such as failing to properly keep medical records, failing to properly document consent for procedures and not securing oxygen cylinders to their carts.
"If an oxygen tank explodes, it's not a good thing. It's a missile," Johns Hopkins Health System President Kevin Sowers told All Children's employees at a town hall meeting earlier this month. "So I need your help in making sure that our oxygen tanks are secured."
The 49-page report supports and expands on a Tampa Bay Times investigation into the hospital's heart surgery unit.
The Times found that the program's 2017 death rate was the highest of any program in Florida.
Members of the medical staff raised concerns about two heart surgeons to the hospital's leaders as early as 2015. But it wasn't until 2017 that administrators slowed surgeries and removed one of the surgeons from the operating room.
Last month, the federal agency placed the hospital in "immediate jeopardy," a rare status that requires the hospital to fix these issues within weeks in order to keep its public funding.
About 5 percent of hospitals nationwide received an immediate jeopardy citation last fiscal year, according to the U.S. Centers for Medicare and Medicaid Services. Only three hospitals lost funding.
Here are some of the citations from the inspectors' 49-page report. Scroll down to read the full document.
_ The hospital's board of trustees failed to protect patients. The board did not properly oversee patient safety in multiple areas like quality of care, medical staff credentialing and infection control. It hadn't looked at survival data related to organ donors since Jan. 2017 even though it's required to every year.
_ The hospital did not track how well doctors were performing. A senior director told inspectors that the hospital did not "collect, track or trend any data" for individual physicians.
_ All Children's had widespread problems with communication. "There was no evidence of any lines of communication or accountability" between risk management and "any of the 17 committees, councils, and departments."
_ The Heart Institute failed to monitor its surgeons' competency. To get credentials, one surgeon provided data on 244 previous surgeries. But the hospital did not review how often patients died or had complications after the procedures. The heart unit also had an increase in surgical site infections in 2017 and 2018.
_ There were systemic failures in preventing infections. The infection control department was not involved in evaluating the hospital environment. The hospital became worse at maintaining proper staff hand hygiene in 2018, but made no changes to improve. All six surgeons who had problems with surgical infection in 2017 and 2018 did not attend a training session for surgeons to prevent those infections. Two of those surgeons were in the heart unit.
_ Nine out of the 10 inspected oxygen tanks were unsecured. "If an oxygen tank explodes, it's not a good thing. It's a missile," said Johns Hopkins Health System President Kevin Sowers.
_ Several wheelchairs and toys were dirty. Wheelchairs that needed to be washed were kept unmarked near the patient entrance. The toy room did not have a system to ensure toys were cleaned regularly.
