Dr. Lloyd Jacobs, University of Toledo Medical Center president, called on all of the institution’s employees to stand ready for intense scrutiny coming soon from a federal agency investigating an error that led to a botched kidney surgery last month.
Dr. Jacobs, speaking Friday to employees at a town hall meeting that was streamed online live, said the Centers for Medicare and Medicaid Services would be undertaking an exhaustive review of the entire facility.
The examination is being made after an Aug. 10 surgery during which a usable kidney was discarded before it could be transplanted into the donor’s sister. UTMC’s live kidney-donor program was voluntarily suspended after the incident.
“At this point, nobody disputes what happened,” he said. “What we really need to do is see if there’s any way to practice the principles of continuous improvement — continuous quality improvement — as it relates to protocols, policies, and procedures ... those are the things that create safeguards.”
He said the imminent review would feel like a joint commission survey.
“This is every aspect of the institution. From Kobacker [Center] to outpatient needs to be ready for a major survey,” Dr. Jacobs said.
Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC, the former Medical College of Ohio, appeared Friday with Dr. Jacobs.
Dr. Gold said the hospital’s kidney-transplant program has a history of excellence and success. He also clarified details contained in reports from the Ohio Department of Health that showed UTMC was cited for violating state standards over the last decade, including one report that said it had a lower-than-average survival rate for kidney transplants during a period of time.
The Ohio Department of Health — which is part of the current investigation — has conducted several reviews at the hospital over the last decade, records show. In October, 2010, the state health department did a survey of the hospital’s kidney-transplant program based on findings by the Scientific Registry of Transplant Recipients, which “revealed that the actual one-year graft [transplant] survival rate was significantly lower than expected for patients transplanted between Jan. 1, 2007, and June 30, 2009.” The state’s report found “the expected number of graft failures was 13; the actual number of graft failures was 22.”
Dr. Gold said graft survival refers to the organ that was transplanted. Six out of the 22 patients died at some point and the others went back to other methods like dialysis after kidney graft failure.
He said the UTMC graft survival average last year was “far superior to any national average.”
“This is a long-standing, highly excellent program that has taken risks for patients, for donors, and for recipients since its inception over 40 years ago,” Dr. Gold said.
The medical center hired Dr. Marlon Levy, surgical director, transplantation, at Baylor All Saints Medical Center at Fort Worth, to “review the policies, procedures, and practices of UTMC’s living related donor program” and to review management of patients undergoing living related transplants.
Dr. Levy’s report on the program has been completed and UTMC officials are weighing requests from media organizations to release that document.
Dr. Jacobs said the report from Dr. Levy found that the Aug. 10 kidney surgery was an isolated incident and not characteristic of the medical center’s culture of safety.
Regarding the voluntary suspension of the live-kidney donor program, Dr. Jacobs has said previously he has no doubt it would be restarted after reviews.
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