Tuesday, December 23, 2014

They Shoot Horses, Don't They?

I took that title from a great movie about depression era dance contests where the dancers danced for marathon hours in the quest for money sorely needed in a time of great economic woes. As some things change some things maybe need to be brought back again. We really do dance in marathons for no reason when it comes to the idea of change in America. And this week more news about the decrepit and disgusting care brought to Veteran's and their families by the hand of the military hospitals that are entrusted with care. How different they are from many of our own public and some private ones remains to be seen.

Well when the Joint Commission (a basically fraudulent accreditation organization that does little to investigate nor have any authority to actually discontinue medical fraud/malpractice) decided to investigate some of the Veteran hospitals under question, they did and found not shockingly, crap care. Then that was that.

What happened in reality was any of the whistleblowers, complainers and rabble rousers were immediately relegated to the broom closet, kicked to the curb or vilified so their careers ruined. Meanwhile crap care continued and apparently still does. Because as we have come to learn that once the media and faux governmental attention leaves town, all things return to normal. Normal being dysfunction. This is America where you love it or leave it and not always by choice.

Military Hospital Care Is Questioned; Next, Reprisals

DEC. 20, 2014
The New York Times

FAYETTEVILLE, N.C. — Beyond conducting their periodic evaluation of Womack Army Medical Center, one of the military’s busiest hospitals, the inspectors who came here to Fort Bragg last March had a special task. A medical technologist had complained of dangerous lapses in the prevention of infections. The inspectors planned to follow up.

But Teresa Gilbert, the technologist, said supervisors excluded her from meetings with the inspectors from the Joint Commission, an independent agency that accredits hospitals. “I was told my opinions were not necessary, nor were they warranted,” said Mrs. Gilbert, an infection-control specialist.

The review ended disastrously for Womack, one of 54 domestic and overseas military hospitals that serve more than three million active-duty service members, retirees and family members. The inspectors faulted infection prevention and many other aspects of care, putting the hospital’s accreditation under a cloud for months.

In March, the Joint Commission found Womack Army Medical Center failed to comply with a long list of hospital standards. Inspectors cited continuing problems in two follow-up visits. A final inspection last month found no violations.

In the initial report, Womack was found to be out of compliance with 19 standards including the following:

Staff are competent to perform their responsibilities
The hospital effectively manages its programs, services, sites, or departments.
The hospital has an infection prevention and control plan.
The hospital plans the patient’s care
The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.

It was disastrous for Mrs. Gilbert, too. She said she was reprimanded for being an obstructionist, reduced to part-time hours, investigated for what she called trumped-up charges and transferred to a clerk’s job.

The message to Womack workers, she said, was clear: “You don’t go against us. If you do, we will get you.”

At any hospital, patient safety and quality of care depend on the willingness of medical workers to identify problems. The goal is for medical workers to be free to speak bluntly to — and about — higher-ups without being ignored or, worse, punished.

In interviews and email exchanges, many doctors, nurses and other medical workers said military hospitals fall short of that objective.

During an examination of military hospitals this year, The New York Times asked readers to recount their experiences via a private electronic portal. Among more than 1,200 comments were dozens from medical workers about how the system thwarted efforts to deliver superior care.

Physicians and nurses described in follow-up interviews how they were brushed off, transferred, investigated, passed over for promotion or fired after they pointed out problems with care.

Senior military health officials said they were working aggressively to instill a culture where complaints are welcomed and addressed.

“We want people to come forward,” Lt. Gen. Patricia Horoho, the Army surgeon general, wrote in a statement. “We are committed to patient safety, we are committed to transparency, and there will be NO COMPROMISE.”

But hospital workers, both military and civilian, described compromise as routine. The nature of military medicine, they say, muddles the emphasis on patient safety and quality of care.

Military hospitals must train a combat-ready medical corps while treating fevers and delivering babies. The staffs are top-heavy with novices, and active-duty medical workers are constantly rotated. Experts say some hospitals are dangerously small.

The command structure is so rigid that a nurse can oversee a doctor because the nurse holds a higher military rank. Promotions often reward administrative deeds over medical performance. Legal accountability is diminished: Active-duty service members cannot sue for malpractice, and other patients can sue only the government, not individual doctors or nurses.

Military supervisors wield more power than civilian ones; they are authorized to enforce rules that govern even the size of earrings a doctor can wear. Stepping out of line can be perilous for subordinates: One former Army radiologist said her supervisor threatened to transfer her to an outpost so remote that the only housing was in trailers.

“In the military you are not taught to question; you are taught to obey. And that’s great on the battlefield,” said Bill Benham, until recently first sergeant of the hospital at Fort Knox in Kentucky. “But health care is another beast.”

Risk in Raising Concerns

An analysis of military hospital data by The Times this year found preventable errors are chronic and rates of complications, when measured, are high in two cornerstones of treatment, maternity care and surgery. The Times also found that hospitals routinely failed to investigate after patients died unexpectedly or suffered permanent harm.

The Pentagon’s own review, ordered in May by Defense Secretary Chuck Hagel, resulted in orders for improvements at almost every hospital. Pentagon officials said they were especially concerned by suggestions of a systemwide shortcoming: medical workers’ reluctance to identify problems.

More than a dozen physicians and nurses interviewed for this article said their own experiences illustrated why. Most insisted on anonymity for fear of further harm to their careers.

A former military surgeon at Womack said he was passed over for promotion after he said that his supervisor had failed to properly examine a patient who later died of cancer. A psychiatrist who worked at Wright-Patterson Air Force Base in Ohio said her supervisor tried to oust her after she complained that residents were not properly supervised. A former anesthesiologist at San Antonio Military Medical Center said his supervisor initiated a review of his credentials after he questioned why she failed to insert a breathing tube in a patient who later died and why another doctor gave the wrong type of blood to a patient.

Dr. Russell Hicks, a psychiatrist, said Madigan Army Medical Center outside Tacoma, Wash., revoked his credentials this year after he identified serious flaws in a program to screen soldiers for post-traumatic stress. “I did what I knew, and I still know, was right, and they went after me,” he said. He has appealed the decision.

Asked about specific allegations of reprisal, General Horoho said officials had investigated and decided that some were not substantiated.

“When they were, we took appropriate action,” she said. She said that the law prohibited her from discussing individual cases and that extensive reviews protected physicians from unfair attacks on their credentials.

But few cases trigger such high-level scrutiny. Dr. Gayle Humm, an emergency room physician under contract at Evans Army Community Hospital in Colorado, said she refused to prescribe narcotic painkillers for patients she suspected were addicted. When some patients complained, her supervisor told her that “the only thing that mattered was that the numbers were affecting his promotion,” she said.

After Dr. Humm, a retired Army colonel with decades of medical experience, criticized the treatment of a surgical patient in 2010, she said, she was let go.

Months later, the hospital’s intensive care nurses gave a deputy commander the medical charts of patients they said had received substandard care.

One nurse who attended the meeting said he asked why Evans did not report and investigate “sentinel events” — cases in which patients had unexpectedly suffered serious harm or had died — as required. “We prefer to call them clinical mishaps,” he said he was told.

Mike Rodriguez, a second nurse, said he resigned in disgust after the complaints were ignored. The civilian hospital where he now works “is not perfect,” he said. “But I can assure you there is no covering up of gross negligence.”

At David Grant Medical Center in California, Danette Lebaron, a pediatrician there for seven years, also said she was frustrated. In 2009, after one infant died and others suffered what she called devastating outcomes, she and three other doctors urged the hospital commander in a four-page letter to close the labor and delivery unit.

“I wanted it on the record that I did everything I could to shut that place down,” said Dr. Lebaron, who has since left. “I was angry that active-duty women, including me, had to deliver our children in an unsafe hospital.”

“Basically, I was told that training residents was more important than patient safety,” she said.

In a statement, Maj. Gen. Mark Ediger, the Air Force deputy surgeon general, said the hospital “provides high-quality care to mothers and babies.”

The unit remains open.

‘Invaluable’ but Pushed Out

Serving the United States Military Academy at West Point, Keller Army Community Hospital occupies a special niche among military hospitals. But that prestige glosses over the ravages of age, reflected in power failures, water shut-offs and balky ventilation. Not long ago, staff members said, a sewage pipe burst in the ceiling of the nursery and waste poured down near the cribs, all of them, fortunately, empty.

Pentagon analysts have argued that Keller sees too few patients — on average, five a day, 11 births a month — to keep medical workers’ skills honed. This year, Army officials beat back a Pentagon recommendation to convert Keller to an outpatient clinic.

Col. Italo Bastianelli, 52, spent 15 years at Keller, most recently as head of the obstetrics and gynecology unit. For a decade, his evaluations were stellar: “Magnificent.” “Invaluable.” “Phenomenal.” “Absolutely outstanding.”

But in 2010, Dr. Bastianelli started complaining that patient safety was taking a back seat to demands to cut costs and fill more beds. Speaking on the condition of anonymity in interviews, five nurses who work or worked there echoed his complaints.

Dr. Bastianelli objected that women in labor were denied epidural anesthesia, violating ethics and policy. He complained that the intermittent lack of a general surgeon on call could be “disastrous” in an emergency. He warned against leaving the maternity ward short-handed and argued that surgery was routinely conducted at temperatures or humidity that increased the risk of infection, and filed a report when staff members moved surgical blood stocks off site during a December 2010 power outage — and then forgot to retrieve them when surgery resumed.

Maternity ward nurses were also upset. In October 2011, they told Dr. Beverly Land, the hospital’s commander, that it was irresponsible to assign them to care for patients in the emergency room or post-anesthesia unit without proper training.

About four months later, Dr. Bastianelli learned that Dr. Land had decided to transfer him. In a private meeting, he said in an interview, she questioned his competence and productivity despite signing two evaluations extolling his performance.

Dr. Land, now serving elsewhere, said she made quality of care the highest priority, welcomed input, and promptly addressed concerns. “At no time would we ever consider making a decision based on budget that would put the health or safety of our people at risk,” she said in a statement.

The Army inspector general’s office swiftly dismissed Dr. Bastianelli’s argument that he was a victim of retaliation, saying he was transferred because maternity cases had declined and the hospital needed “a fresh perspective.”

After a lifetime of treating patients, Dr. Bastianelli is now an administrator, working as deputy commander for clinical services at Fort Dix in New Jersey.

He said his trust in the system was gone. “Simply put, I was targeted because I wasn’t a ‘yes man’ and stood in the way,” he said.

“The Army surgeon general wants the medical staff to speak up about patient safety and quality concerns,” he said. “I spoke up and was retaliated against.”

“That sends a message,” he said.

Keller’s troubles persisted after his departure. In August, the inspector general concluded that while patient care met safety standards, the hospital staff was deeply frustrated. “Employees believed that violations of standards are overlooked and that regulations and safety requirements are not always followed or enforced, and some felt they would be ‘punished’ if they ‘make waves’ or raise issues counter to their leadership,” the report states.

Two months later, after a surprise inspection, the Joint Commission gave Keller 60 days to correct problems with infection prevention.

Whistle-Blowers Shunned

“Regardless of whether there is the reality of retribution, if there is a perception of one, that is going to stifle open discussion,” Vice Adm. Matthew L. Nathan, the Navy’s surgeon general, said in an interview. One way to counter that, he and other senior health officials said, is to publicly celebrate whistle-blowers’ courage.

If you have had a first-hand experience with the nation’s military’s health care system, as a patient, family member or worker, please tell us your story by filling out this form.

When it came to Teresa Gilbert, the technician at Womack, complaining about dangerous lapses in the prevention of infections did not make her a heroine. Instead, she said, it made her a pariah — shunned by co-workers and marked for dismissal.

Unlike sleepy Keller, Womack is one of the Army’s busiest hospitals, serving about 55,000 active-duty service members at Fort Bragg and their families. Mrs. Gilbert, 51, said she began to raise concerns after the hospital’s infection-control chief retired in late 2012 and was replaced by a parade of successors lacking any special training.

Analysts with the Mihalik Group, a health care consulting firm hired to scrutinize Womack before the hospital’s accreditation review in March, were also concerned. In a confidential October 2013 report obtained by The Times, they faulted the hospital on nearly 60 performance measures.

Emergency room patients were improperly screened and charts were incomplete, even for patients undergoing high-risk procedures, the report said. Medication was not labeled with patients’ names. One patient was incorrectly categorized as a “do not resuscitate” case. Low-level nurses assessed patients and planned care without the required supervision.

The analysts zeroed in on infection control, warning that the Joint Commission could consider failures there an “immediate threat to life.” They found that staff members left unsterilized instruments out for emergency use, failed to properly disinfect medical devices and could not document their competence in sterilization.

“The findings here are extremely serious and put patients at risk,” the analysts wrote. “Immediate correction is needed.”

Mrs. Gilbert called the report “frightening.” In January, when the hospital failed for three months to act on it, she alerted the Joint Commission.

Two months later, inspectors found the hospital was violating 19 standards, including infection control, management, staff competence and patient safety. Womack remained accredited, but follow-up inspections were ordered.

Before the next one, disaster struck. In mid-May, a 29-year-old mother of three died after two residents performed a routine tubal ligation and emergency room nurses failed to identify her case as a priority when she returned that same afternoon in pain.

Already under fire for the accreditation problems, the hospital commander was dismissed and his deputies were replaced. Separately, the Army ordered an investigation into why inspectors had found that Womack violated infection-control standards. In July, Brig. Gen. Robert D. Tenhet, the medical commander for the region encompassing Womack, handed Mrs. Gilbert a letter suggesting why: She was to blame.

“While you were quite knowledgeable in your field, you were very difficult to work with,” it cited other hospital workers as saying. “Specifically, you were characterized as an obstructionist and someone who withheld critical information.” In a statement, General Tenhet said he could not discuss individuals but must sometimes counsel staffers who have raised patient safety concerns about unrelated performance issues.

Contradicting Evaluations
In the five years before she reported lapses in the prevention of infection at Womack Army Medical Center, Teresa Gilbert’s performance was typically judged to be excellent. That included her ability to work with others, as reflected in notes from her superiors in annual evaluations.
July 14, 2014
After Mrs. Gilbert alerted outside inspectors of the problems, a senior army medical official criticized her performance.

More serious allegations followed: Mrs. Gilbert was accused of improperly gaining access to her own medical records and those of Tiffany Tighe, her son’s girlfriend, and disclosing Ms. Tighe’s medical information to one or more people.

In a telephone interview, Ms. Tighe said the charges left her dumbfounded. When an Army investigator called her in July, she said, she insisted that Mrs. Gilbert had never violated her privacy. “He told me that the case would be closed for lack of evidence,” she said.

It was not. That month, Mrs. Gilbert was transferred to a clerk’s desk, without a computer, a telephone or duties. “People I have known for 20 years were afraid to talk to me,” she said.

Recent months have been tumultuous. Mrs. Gilbert said stress-related medical problems forced her to stop working. She received three notices that the hospital intended to fire her for patient privacy violations and absences. Asked about the case this month, an Army spokeswoman cited “multiple substantiated disciplinary infractions.” On Wednesday, after inquiries from The Times, the Army suspended any action for 60 days.

“I just can’t believe the lengths that they are going to,” Mrs. Gilbert said. “Before this, I have never been written up for anything. I have never had a bad evaluation, ever.

“I never imagined it would be like this.”

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