"On December 22, 2016, Detroit Medical Center was resurveyed by the Michigan Department of Licensing and Regulatory Affairs (LARA). During this follow-up survey, LARA verified that the hospital has addressed LARA’s prior findings regarding the hospital’s processing of surgical instruments and made no new findings. We are pleased that we resolved this matter to LARA’s satisfaction and that the hospital is in compliance with regulations designed to protect the health and safety of patients who entrust us with their care.”
Nothing is more important to us than the safe, quality care we provide to the residents of Detroit. We have many exciting projects and service offerings to look forward to in 2017 and are proud to continue to build on our 150 year legacy of service in our city.”
Click here to view the communications from LARA.
“Detroit Medical Center is pleased to report that the hospital has been resurveyed by the Centers for Medicare and Medicaid (CMS) on November 1st and 2nd. During their survey, CMS found no deficiencies related to the processing of surgical instruments. The hospital is in full compliance with CMS’ Conditions of Participation.
DMC is working with LARA throughout this process as the State’s consultant continues to review our Plan of Correction for LARA.”
Click here to view the communication from CMS.
The Detroit Medical Center Plan of Correction that addresses all findings identified in the recent survey of the hospital’s sterilization program has been submitted to and approved by the Michigan Department of Licensing and Regulatory Affairs (LARA). This plan is separate from the plan submitted and approved by CMS last week and both agencies are working in coordination to ensure all of the findings are resolved.
Similar to our CMS Plan of Correction that was posted on October 11th, the key elements of our plan, some of which have already been implemented, include the use of a perioperative improvement council and task force to oversee our actions to improve operational protocols and sterilization processing. Additionally, we aligned our training and competency documents with DMC’s revised infection control policies, enhanced training for relevant staff regarding cleaning practices as well documentation of these trainings, and upgraded auditing and monitoring of these revised processes. In June, prior to the survey, DMC engaged highly regarded external specialist Unity HealthTrust to manage DMC’s instrument sterilization process as well as promote process consistency between operating rooms and the CSP department.
DMC will continue to work collaboratively with the State until all matters are resolved and validated by both the State’s consultant and the upcoming resurvey.
Click here to view the Plan of Correction.
“Detroit Medical Center has submitted a Plan of Correction to CMS to address all findings identified in the recent survey of the hospital’s sterilization program, which has been approved. As part of this process, CMS will conduct a follow-up survey to validate the effectiveness of our actions and we will continue to work collaboratively with them until all matters are resolved. As promised in our statement on September 15, we are releasing both the survey report and our Plan of Correction to help the community better understand both the findings and our commitment to resolving all of the deficiencies.
We take the survey results very seriously and through the collective efforts of our management, partners and employees we will take all actions necessary to correct the findings. The key elements of our plan, some of which have already been implemented, include the formation of a perioperative improvement council and task force to oversee our actions to improve operational protocols and sterilization processing. Specifically, our plan addresses improved policies and procedures for cleaning, processing and sterilization of surgical instruments, enhanced training for relevant staff regarding cleaning practices, and upgraded auditing and monitoring of these revised processes. In June, prior to the survey, DMC engaged highly regarded external specialist Unity HealthTrust to manage DMC’s instrument sterilization process.
We will also be submitting a Plan of Correction to the Michigan Department of Licensing and Regulatory Affairs (LARA) and will post it to this website once it has been submitted and approved. The trust of our community is paramount as we continue to build on our 150 year legacy of quality care to the residents of Detroit.”
Click here to view the findings and Plan of Correction. Click here.
Detroit Medical Center (DMC) and the Michigan Department of Licensing and Regulatory Affairs (LARA) have entered into a cooperative agreement regarding the recent assessment of DMC’s Central Sterile Processing function. This agreement includes the utilization of a third-party consultant with expertise to advise the State on the implementation of the hospital’s corrective action plan in regards to the survey and findings. DMC and LARA are committed to successful resolution of this matter and will work in coordination until the hospital has been resurveyed by the State and found to be in full compliance.
What does it mean to enter into a “cooperative agreement” with the Michigan Department of Licensing and Regulatory Affairs?
This step with the State supports DMC’s effort to provide high quality care. The State will utilize a third party consultant with expertise to advise the State on the hospital’s implementation of its corrective action plan.
Why did DMC make this agreement with the State?
DMC is working with the Michigan Department of Licensing and Regulatory Affairs to address the issues found in its recent assessment of our Central Sterile Processing (CSP) department and related areas.
What is the consultant’s responsibility?
The consultant will work with DMC on the implementation of its corrective action plan.
What actions are being taken by DMC?
In June, DMC outsourced its CSP management to Unity HealthTrust, a highly regarded organization with expertise in overseeing CSP functions. We continue to work closely with Unity to enhance operational efficiencies in this critical department. Additional actions being taken include leadership and structural standardization, improved education, training and competency documentation, and improved auditing and event monitoring.
Click here to view Agreement.