The Shadow Practice, Part 11: Joint Commission overlooks risky practices that led to patient death
The surgeons at Anaheim Hills Surgery Center had to be sweating.
The Joint Commission, one of the most powerful arbiters of whether a health center is deemed worthy of federal funding, showed up at the surgery center's doorstep in April 2008 to review its records, its practices and its staffing.
The timing was terrible.
Just one month earlier, the center had added a brand new skeleton to its bulging closet.
Maria Garcia, 39, had died on the operating table after back-to-back plastic surgery procedures in an unlicensed setting, her vaginal wall punctured by an errant surgical instrument.
The Joint Commission has broad authority that allows it to review a facility from top to bottom, check patient records and trace patients from the beginning of their experience with a health center until the end. As with all Joint Commission reviews, the public was not allowed to see the details of the surgery center's survey, but the final result was clear: Anaheim Hills Surgery Center was given full accreditation effective August 7, 2008.
The doctors must have gone out clubbing after getting the news.
How a medical office could win the Joint Commission's seal of approval one month after a tag-team surgery that used unauthorized doses of anesthesia and left a patient dead is worth an entire investigation all its own.
Let's assume Garcia's death was simply missed by the Joint Commission when reviewing the surgery center's files. The Orange County Sheriff Coroner Division had called the death a "therapeutic misadventure" and declined to turn the case over to prosecutors, so there would have been no red flag there.
Should the Joint Commission have checked with the Medical Board of California to see whether the medical staffers at Anaheim Hills Surgery Center were good candidates for the commission's much-coveted gold seal? The Joint Commission publishes an entire handbook on credentialing medical staff.
Here, too, the Joint Commission would have come up empty. Garcia's death wasn't even on the medical board's radar at the time. The coroner's office apparently did not report the death to the medical board. Nor did Kaiser Hospital-Anaheim, where Garcia was pronounced dead. Neither of them, by law, had to report the death. The main parties responsible for reporting Garcia's death to the medical board would have been the two surgeons who operated on her: Dr. Lawrence Hansen and Dr. Harrell Robinson.
Neither Robinson nor Hansen reported Garcia's death to the board, according to board documents.
Instead, the board did not find out until much later. Nearly two years after Garcia's death, the board in December 2009 charged Hansen with gross negligence, incompetence, failure to report a death, performing surgery in an unaccredited facility, and general unprofessional conduct.
The board documents contain some stunning details, even for a surgery this poorly executed.
How about this?
"During subsequent interviews, respondent was unable to recall the procedure he had performed on [Garcia]."
"Upon learning that [Garcia] had been transferred to the hospital due to complications, respondent did not act on and/or feel the urgency to go and evaluate the patient."
The Joint Commission visited again in July 2010. At this point, there was no excuse for the Joint Commission to overlook the problems at the center. Hansen already was facing medical board charges related to Garcia's death, and all the details the commission needed could be found in the medical board's public files. Robinson had lost his license in June 2009 after using the clinic as part of an illegal black market in painkillers that resulted in the U.S. Drug Enforcement Agency taking away his ability to prescribe narcotics. Two other doctors on staff also faced medical board charges.
The Joint Commission could have found out all of this information with ease. Yet, in July 2010, it gave Anaheim Hills Surgery Center full accreditation again.
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Next: How a little-understood court ruling has weakened oversight of surgery centers