Joint Commission (JC) Standards Report

December 23, 2011

To Whom It May Concern:

Re: A v. Heart Hospital of Austin et al

My name is **********************. I have been a hospital chief executive officer and healthcare administrator for over 35 years and currently am a full-time educator and consultant to hospitals and health systems throughout the United States. Since 1978, I have been a Board Certified Fellow of the American College of Healthcare Executives (“FACHE”), which is the professional organization for hospital administrators, having passed the certifying examination and have been recertified as required by the College. I have lectured extensively to hospital administrators and students in hospital administration and have been a featured speaker at several national meetings. I am currently a faculty member in the graduate and undergraduate health administration programs at the University of ***** and teach at least one course every semester. I have also written a book entitled **************************. I have been continuously employed in the field of hospital and health care administration since 1973. I am familiar with the prevailing professional standards of care for acute care hospitals, such as the Heart Hospital of Austin, Texas, which is the subject of this letter for events occurring in January, 2011. More specifically, for such time period, I am familiar with standards of care and obligations applicable to such hospitals in their care of patients who present through an emergency room and are then admitted. Further information regarding my experience and qualifications is detailed on my attached CV.

At your request, I have reviewed the medical records for Mr. K at Heart Hospital of Austin (HHA) from January 4, 2011 through January 11, 2011 and the death certificate for his death on February 5, 2011. I understand that Mr. K was transferred to Seton Hospital on January 11, 2011 but his condition at that time was grave from anoxic encephalopathy sustained January 5, 2011. At Seton Hospital, it is my understanding he was there until his death and at this facility he received in essence just supportive and palliative care. His death certificate confirms that he died from the anoxic encephalopathy that had been sustained approximately a month earlier. I will address hospital standard of care issues concerning Mr. K’s hospital care from his admission, and how such standards were breached by the hospital (HHA) and its personnel.

A brief summary of the case indicates that Mr. K underwent coronary artery bypass surgery at HHA on January 4, 2011 by a cardiovascular surgeon, Dr. O. He subsequently developed complications, including a swollen neck, bleeding from his chest tubes, and eventually respiratory and cardiac arrest by about 7:20 a.m. the next day. The HHA staff repeatedly contacted Dr. O and his anesthesiologist, Dr. B, to inform them of his worsening condition throughout the night into the morning of January 5, 2011. Neither physician ever came in to see Mr. K until Dr. B came in at 7:20 a.m, which is the same time that Mr. K coded. Further, Dr. A was called urgently regarding Mr. K’s new development of stridor at 7:05 a.m, but Dr. A did not come see the patient, indicating that Dr. B would be in “soon.” After the code procedure, Mr. K was then taken for emergency surgery by Dr. O who removed a blood clot. During the code procedure, Mr. K was without heart function for approximately 8 minutes and suffered anoxic encephalopathy. He was provided supportive and palliative care thereafter, and passed away on February 5, 2011.

I have been asked to evaluate the degree of compliance of HHA with the standards of care, some of which are based on the Joint Commission (JC) Hospital Accreditation Standards. The JC is the organization charged by the federal Centers for Medicare and Medicaid Services for approval to participate in those programs, and is also utilized by many states as the authority for hospital state licensure. Compliance with JC standards is required for any reasonably prudent hospital. Therefore, I have reviewed the documents listed above, and the JC Hospital Accreditation Standards for 2011. HHA, as part of St. David’s Medical Center in Austin, Texas, is a JC accredited hospital and was at the time in question so these JC standards are applicable to such entity.

It is my opinion, based upon my experience as a hospital administrator and consultant, within a reasonable degree of professional certainty that the care provided to Mr. K by HHA and its employees was not consistent with certain specific JC standards detailed below, and therefore violated such standards.

JC Standards for Hospital Leadership (LD) provide guidance on the governance and management of the hospital, as well as the delivery of care by all physicians, nurses, and others. Leaders are ultimately responsible for planning, directing, and providing all care delivered to patients.

LD.01.03.01, “The governing body is ultimately accountable for the safety and quality of care, treatment, and services.”

LD.04.03.01, “The hospital provides services that meet patient needs.”

LD.04.01.07, “The hospital has policies that guide and support patient care, treatment, and services.”

These standards describe the responsibilities of the leaders of the hospital for the care that takes place at their organization. They must provide the services their patient’s needs and must have policies and procedures in place to address the foreseeable circumstances that may occur. It is especially important to note that an organization that presents itself to the public as a ‘heart hospital’ must be ready and able to address the types of issues that arise when patients undergo heart surgery, including those that would apply when a patient is in need of emergent physician evaluation and care post-operatively, yet his or her attending physicians are not responding as necessary. It is unknown at this time if HHA had appropriate policies, but it is likely that they did and that the policy specified a time frame for physicians to respond to calls regarding their patient’s emergent care needs, as well have alternatives ready for when they did not. HHA should have had their own internal policies, procedures, and protocols, that would that would have caused hospital personnel to timely provide for adequate patient care in terms of responsiveness and intervention by a patient’s treating physician, or an alternative physician if need be. HHA either did not have these policies, or their staff did not follow them, but either way this was sub-standard conduct by the hospital.

JC Standards for the Provision of Care, Treatment and Services (PC) are designed to define the successful coordination and completion of patient care processes, including the assessment of patient needs, the planning for care, the actual provision of the care needed and the overall coordination of all patient care services.

PC.01.02.03, “The hospital assesses and reassesses the patient and his or her condition according to defined time frames.”

PC.02.02.01, “The hospital coordinates the care, treatment, and services based on the patient’s needs.”

Despite his worsening condition and repeated phone calls to Drs. O and B who did not come to the hospital, HHA staff breached this standard because they did nothing to provide other physicians to care for Mr. K. His condition changed significantly over the course of several hours and hospital staff allowed this to occur as they took no action concerning providing the patient timely and necessary physician evaluation and care, other than to place calls to physicians who did not return to care for Mr. K. As reflected in the (DATE) report of *******, RN, in the late evening of January 4, 2011 and throughout the early morning hours of January 5, 2011, Mr. K was in a significantly deteriorating condition and in need of urgent physician evaluation and care, and the nurses of HHA should have known and acted on that circumstance. This is also confirmed by the (DATES) reports of Dr.****** and Dr. ******.

In regards to these two standards, HHA is required to, in a timely fashion, coordinate the provision of care to patients regardless of the actions taken by various providers, in this case, Dr. O, Dr. B, and Dr. A. HHA did neither. Because Mr K’s condition was declining, it was incumbent by the hospital staff to insure that the patient’s treating physicians, Dr. O and Dr. B, were not only timely notified but that they timely respond by examining the patient and formulating an appropriate medical care plan. HHA should have had their own internal policies, procedures, and protocols, that would that would have caused hospital personnel to timely provide for adequate patient care in terms of responsiveness and intervention by a patient’s treating physician(s), or alternative physician(s) if need be. HHA either did not have these policies, or their staff did not follow them, but either way this was sub-standard conduct by the hospital. During the initial hours of January 5, 2011 until the time of the code, the hospital should have followed up with another physician when he did not respond. There was, or should have been, a Chief of Section or Chief of Staff physician who should have been notified so that either he or she could have personally evaluated and cared for the patient, or secured the services of on-call physician(s) to do so. Instead there was a period of approximately 8 hours where Mr. K’s condition continued to worsen significantly and no physician came to see him until the same time he coded.

This same situation also existed concerning when Mr. K unequivocally showed signs of stridor (an emergency respiratory condition) yet Dr. A, after being contacted at 7:05 a.m. by the nurse indicated he would not be coming to see the patient and another doctor would be coming in the vague time frame of “soon.” HHA’s own internal policies, procedures, and protocols, should have either existed to require the contacting of another physician for such emergency, or the HHA staff should have followed them if they existed by making sure another physician was contacted and urgently came to see Mr. K. Nurse ***** and Dr. ****, also address this issue in their (DATE) reports, as well.
The conduct described above are direct violations of both the letter and spirit of these standards of care, and HHA should have made certain that Mr. K was timely and cared for properly, but it did not.

All of the various departures identified and discussed above from the mandatory standards of the JC adversely impacted the provision of necessary care and treatment for Mr. K and, with a reasonable degree of administrative certainty, breached the standard of care owed to him by HHA and its staff.

Should any additional information become available to me, I reserve the right to modify or supplement this opinion.