Does the DOH intentionally ignore complaints / deaths that occur at VMC?

The statistics are coming in as I hear from you. The answer – you bet the DOH ignores VMC errors.

I have updated this post with a lot of new information that details how worthless and dangerous these DOH organizations are. They do not want the public to know what is exactly going on in the State healthcare system and do not enforce hospital reporting of preventable adverse events. As far as I can tell, none of the errors that happened to Mark were included on the DOH adverse event log or the DOH hospital acquired infection numbers.

If you have filed any complaints with the DOH Medical Quality Assurance Commission (MQAC), Facilities and Licensing and/or the Nursing Commission I’d like to hear from you. You may also want to read on as I will expose what I located about a Registered Nurse, Jill Stevens, who was also an investigator for the DOH Facilities and Licensing and the mental issues she has faced for years. I will also provided links to the data I obtained from the court system. Even with all the mental issues Jill Stevens has had for years, the DOH let Jill “investigate” patient complaints and even allowed her to renew her Registered Nursing credential in April. UNBELIEVABLE. Jill Stevens, Rn, will have her sentencing on November 5^th. I plan on being there and hope to speak.

 My personal email: karieturn@comcast.net

I never realized how corrupt the disciplinary and investigative process is. I sent in 2 separate binders full of hospital errors backed with the data that happened at Valley Medical (VMC). This was new information that none of the investigators at any of these State offices had seen. Dr. George Heye, MQAC, actually had the balls to write that I didn’t send anything new in. I’ve only just begun on pushing the issue up the flag pole.

The most alarming part is that in reviewing Mark's records I discovered that Dr. Wynne Chen was fully aware that another patient acquired the same bacteria Mark did (Pseudomonas and Burkholderia) during his hospitalization. Dr. Chen received a phone call from the VMC Lab on December 27 and Dr. Chen and the lab discussed further. Even with Dr. Chen knowing this, he never spoke up in any of our family conferences/meetings with the truth that Mark acquired all the bacteria there (and not in another state many, many years ago as Dr. Michael Hori suggested). What ever happened about being ethical? I guess that doesn’t apply to doctors or hospitals.

Thank heavens I set up this blog as many others have come forward, "Whistleblowers" from VMC that should have been protected for telling the truth (and helping other patients) but were harassed into leaving VMC. All regulatory agencies are now fully aware of these facts and I did have a chance to talk to a "Whistleblower's" lawyer. I wish this person the very best of luck as I believe this "hero" is a leader in ethics (something hospitals have a hard time with), an employee a hospital needs to keep for the quality system to function properly, a person that probably saved lives at VMC and a person that needs to be a voice in healthcare reform. I will always protect their name.

In summary of what I sent out were 2 binders full of appeal data - new information that detailed exactly what happened. The first binder contained mainly medication errors: sent to the State of Washington Department of Health (DOH) Medical Quality Assurance Commission (the MQAC), DOH Facilities and Licensing and also to Qualis (the “[non-]hammer” to ensure patient safety of Medicare beneficiaries).

The second binder I sent to everyone was in response/appeal of a 4 paragraph report (discussed below) written by DOH - CMS Investigator, Jill Stevens, Rn. Jill Stevens has severe mental issues and just renewed her nursing license, has no business investigating anything. Jill Stevens wrote a report 4 paragraphs long. It's word for word what Dr. Richard Wall (VMC Medical Director) told us, but the medical records do not back up. In one paragraph in this investigative report Jill Stevens says: “I reviewed audit results for personnel hand washing in all patient care units - last quarter 2010 to first quarter 2011.” Gee, UW VMC employees are washing their hands and an audit actually captured that? Do employees comply when an auditor is standing over them? REALLY?  Jill Stevens has no other idea how infections are transmitted and never performed a compliance review against 42 CFR 482.13 (Patient Rights) and 482.42 (Infection Control). Not only is Jill Stevens a lousy investigator – she probably had no idea where she was or what she was doing due to her “addictive habits” and her feelings of being “above the law.” It’s in the court records.

In both of these cases (with the MQAC and DOH - CMS), no one read the medical records and it is very obvious that Public Hospital #1 (UW VMC) is being protected by the State of Washington DOH. In both cases, it appeared that VMC wrote the report themselves and the VMC Risk Management Officers are very good friends with the DOH investigators (probably because they are being investigated all the time). Can you say "Conflict of Interest?"

What was very alarming is that Qualis actually found several Quality of Care issues in Mark’s hospital stay/death – and our own Department of Health for the State of Washington found nothing? WHY NOT?

Note: The MQAC monitors complaints against doctors; but the Chief Investigator, Jim Smith, at the September 30 commission meeting walked by me and said “our job is to get them [the doctors] out of a malpractice suit” Imagine my horror when I heard this; I immediately wrote a letter to our State representatives and Governor with my concerns about his comment and conflict with the MQAC mission statement. Others have come forward with similar concerns voiced about this Chief Investigator. And to top this off, those that work in the MQAC actually gave this guy an award for Investigator of the Year (or month or day – who cares because it’s wrong).

What should be very alarming to all is the fact the DOH Facilities and Licensing had the data on the whistleblower and the report that another patient acquired the Burkholderia and Pseudomonas after Mark, but they refused to investigate further (to look at any of the records to see who had procedures done prior to Mark that had the bacteria present). My audit findings of this report alone totaled 30 pages of issues Jill Stevens failed to note. And we, the taxpayer in the State of Washington, actually paid for Jill’s salary.

Something else to alarm all of us is a recent phone conversation I had with an Ex-VMC employee in housekeeping. I was told that the housekeeping supervisor (over the operation room cleaning) went out on a leave. Another supervisor took over and had the employees cut the operating room cleaning to a minimum (less than 8 minutes between patients). While the employees complained; the supervisor’s decision stayed in place. This Ex-VMC employee was apologetic - and very informative on the other issues UW VMC currently faces. Apparently, VMC has done some housecleaning of their own and the supervisors have been replaced.

I also received a 4 page investigation report from the MQAC (well, almost 4 pages). Contained in these records I received from the MQAC were all 49 pages printed of this blogspot, the MQAC actually went and did a search for me on “MySpace,” and out of the 281 pages I had to pay for to receive, only 10 pages contained investigation records. 

I want everyone to keep in mind as your read below that current state laws prevent anyone from appealing an MQAC investigation even though it will contain tons of misinformation not backed by any facts and data and is not audited against any Federal process (it’s only their opinions). Can we appeal a traffic ticket? Can we appeal a Medicare financial decision? Can we appeal a charge on our credit cards? You bet we can, but you can’t appeal the MQAC even though they are wrong (all appointment by our Governor)…

When I received the MQAC "investigation reports" the MQAC investigator (this time Connie Pyles) says that a 3^rd party review had occurred and VMC did nothing wrong. There are no records anywhere of this 3rd party’s review and are not included in the records sent to me. The MQAC didn’t bother requesting the review because they knew it never happened.

Since the MQAC was so concerned about searching for me on the internet I felt it prudent to search on the doctor that wrote the report, Dr. George Heye. What did I find? Dr. Heye is a “General Pediatrician” born in 1941 (72 YEARS OLD) that is grandfathered into the American Board of Pediatrics system. He is certified, 1984, and does not meet the requirements of maintenance of certification in “General Pediatrics” - “prior to 1988 certification was granted for life.” “The new process requires 6 core physician competencies that include communication skills, professionalism, medical knowledge, patient care, practice based learning and improvement which includes the ability to measure and improve quality of care and system based practice.” And the DOH feels this doctor is qualified to report out on such a complex case of medical errors? Go and search for this doctor here.

Dr. George Heye, this “General Pediatrician,” (according to others that have come forward) is the MQAC “Gatekeeper.” This doctor not only does not read the complaint, the medical records (must be a requirement for being a doctor in the State of Washington) and makes statements throughout his report that are incorrect. His report contained a lot of “emotions” he is feeling about me (clearly irritated that I made a complaint in the first place and against doctors, the system and VMC), his report is not based on facts and data, and he continually provides statements that have no bearing on my complaint at all. His unprofessional attitude, lack of understanding of modern day public expectations and lack of knowledge in auditing is appalling. Read a couple of Dr. Heye's comments below (and please send me your feedback):

I'm sure the facility lost a lot of money by keeping him there for the entire time-seems like concern for a conspiracy among the doctors

DR. HEYE, This is a CONFLICT OF INTEREST. First, the State Government auditing a State (Public) hospital – then we have a doctor who obviously doesn’t believe in sanctioning doctors (from your comments and my notes at the MQAC Board Meetings) – then we have an old doctor that is trying to save the old system (cover it all up).

Why are you focused on the hospital losing money when that has nothing to do with my son’s death and my complaint? The entire hospital bill was paid in full (over $1.2M) – and it shouldn’t have been because of regulatory guidelines in place on preventable medical errors and harm. OH, Federal Regulations only have to followed by the aviation industry and not health care - right?

DR. HEYE, YES, THAT IS THE CONSPIRACY – why are you not investigating the complaint and looking at the costs and worried about the poor hospital? MY SON LOST HIS LIFE DUE TO THEIR NEGLIGENCE. 

Categories of the mother’s dissatisfaction include...lack of the ability to get a second opinion within the facility

Why on earth would I have wanted a second opinion from any VMC doctors after all the preventable medical errors and harm they did to Mark? OMG, you don’t get it.

I can address the concerns in regard to the medical care but allegations about nursing care, the facility and the circumstances around his transfer/lack of transfer to another facility are not under the purview of MQAC

THEN DR. HEYE ACTUALLY INCLUDES THE BELOW:

but no transfer ever happened, probably for multiple reasons-he was critically ill and the reimbursement system probably gave no incentive to the second hospital to take on his care…

The patient's mother has complained to multiple other organizations/entities including the governor, Medicare/Medicaid, her state legislators, the medical center, the joint commission, Centers for Disease Control, OSHA, the public Health Department, and her insurance company.

The patient's mother is keeping a blog in regard to her son’s hospitalization with multiple postings on various aspects of the patient's care "mistakes."

A major contention by the complainant is that the first two bacteria were introduced because of lack of sterile technique at the time of intubation and the latter two bacteria became prominent because of use of the "wrong" antibiotics”

DR. HEYE, Where did this come from? ALL THE BACTERIA were from the lack of sterile technique at Valley Medical Center (VMC)! Administration of antibiotics was literally a shotgun approach with no acknowledgment of the culture and sensitivity reports.

Despite the complainants assertions that the wrong antibiotics were used multiple times, NO bacteria were ever isolated from any blood cultures-I believe over 40 were obtained throughout the hospitalization one would have to conclude that appropriate antibiotics WERE given because no uncontrolled bacteremia was ever documented!

DR. HEYE, Why can’t you read anything? THIS IS ON MARK’S DEATH CERTIFICATE!

The complainant makes a big deal that the patient was not given a certain antibiotic...She has misread the report

DR. HEYE, There were multiple reports…which “ONE” report made you come to the wrong conclusion (AGAIN)?

She is upset that the patient was given steroids

YOU BET I AM. Check out why (see this link on Dexamethasone and Mark's WBC) – DR. HEYE, did you look at any lab results at all? Moron.

She contends the doctors identified the patient has been diabetic when he wasn't

DID YOU READ THE PHYSICIAN CONSULTATIONS FROM THE FIRST DAYS? NO!!? MARK WAS NOT DIABETIC.

The complainant felt "a second opinion was something that a neutral 3rd-party would perform by coming into the hospital and independently reviewing the case and assessing the patient and was not something that occurred by, having physicians familiar with the case, give details and opinions ahead of time

DR. HEYE, how do you know how I felt? Was this in a medical record that you were supposed to be reading? We didn’t want VMC involved in screwing up anything else and we were going to meet with this doctor over at Swedish – until VMC DR. SUZANNE KRELL shut down our and Mark’s hope of getting a real second opinion…the Swedish doctor wanted nothing to do with VMC and their errors…Even VMC Risk Manager Steve Haton said the same.

Complaints about communication among physicians was brought up repeatedly-I think the expectation that every physician managing the patient should sit down with the complainant/patient advocate every day and go over all the developments something that would be impossible as the doctors do their rounds at all different times

Again, DR. HEYE, how do you know what I expected – were you there? I have documented each and every conversation with a doctor and it wasn’t each and every day. Why are you discussing my “emotions” when this has nothing to do with my complaint and the death of my son, Mark?

NO VMC DOCTORS CAME BY EACH DAY AND “SAT DOWN WITH US.”

If your child or grandchild was in the hospital or the Intensive Care Unit (ICU), all family and advocates EXPECT daily tie-ins with the doctors and staff. I am assuming you have no children and most likely no family if YOU really believe what you write. Are you suggesting that parents wait a week until the VMC ICU doctor (who has 26 OTHER PATIENTS) has the “time” to discuss your loved ones status?

DR. HEYE, Health care is a business and it appears you are out of touch with modern day reality. The expectations of patients and families in this new age are something that is covered in continuing medical education. OH, WAIT, I LOOKED YOU UP ON THE AMERICAN BOARD OF PEDIATRICS AND YOU DON’T HAVE TO DO THAT! My opinion is that your lack of knowledge is due to not working in a practice or hospital for what…25+ years? DR. HEYE, you need to put down the pipe. 

The complainant would often ask the same question to multiple different specialists and they would give their opinion, which would sometimes not be entirely consistent with what was said by another physician-this doesn't mean they are wrong or not in agreement, just giving their opinion based on their training.

YOU ARE KIDDING…Right? Why would I ask a Pulmonologist (lungs) a question about Mark’s brain? Why would I ask a nephrologist (kidneys) a question about Mark’s lungs? YOUR COMMENT ISN’T EVEN LOGICAL….

The complainant feels that there was inadequate communication as well based on the fact that every new detail about the case was not discussed with her-some of the issues brought up in her letter don't have any effect on the overall management of the patient.

Again DR. HEYE, all patients and advocates expect to know all “NEW” details when their loved one is hospitalized in an ICU. Get used to it. VMC doctor communication was poor at best so don’t give them that type of credit and it had everything to do with the management of the patient. If you look in the 2 binders of data I sent you my comments are solidified with facts and data and not the “feelings” you continuously write about in your report. Tons of details were never discussed or even reviewed by the VMC doctors.

If the doctor doesn’t have time to review new details with the patients and/or advocate maybe the taxpayer funded hospital needs to: Fire the Leadership? Fire the doctors? Hire more staff? Have 1 project manager that follows patient cases that become complex because of medical errors?

The hospital did not operate as she felt it should much of her opinion on that is lack of understanding of medical practice; some of it is because her expectations were too high in regard to communication, but some of her complaints are potentially legitimate but unanticipated

What does any of this have to do with my complaint about hospital acquired bacteria and all the errors that caused my son’s death? I understand more about medical practice and the business than you do. Did you even read my original complaint and the new information? You are out of touch with investigating.

And we the Taxpayer actually pay for the MQAC (and your salary) to provide biased, unsupported reviews of our complaints so that the hospital errors, deaths and hospital costs continue to escalate out of control? If someone doesn’t take charge and put a cog in the DOH wheels nothing will ever change. Since the State of Washington Legislature gave the medical commissions power to run out of control (with no check and balance system), maybe it’s time the people take control away?

MANY OF US ARE UP FOR THE CHALLENGE.

THE DOH WILL BE EXPOSED….