“The Centers for Medicare and Medicaid Services has accepted the Plans of Correction that were submitted by Detroit Receiving Hospital, Harper University Hospital and Children’s Hospital of Michigan which addressed all findings identified in the hospitals’ recent surveys. As part of this process, CMS will conduct a follow-up survey to ensure DMC is in compliance with the Medicare Conditions of Participation for hospitals. We will continue to work collaboratively with CMS until all matters are resolved.
The key elements of our plans, many of which have already been implemented, include extensive reorganization of the Central Sterile Processing Department; review of all processes related to the pretreatment, decontamination and sterilization of instruments; investment in new instruments and equipment; and implementation of instrument assessment and inventory process. We are continuing the efforts that the Perioperative Council put in place in the fall of 2016 including daily discussions with clinical and hospital leadership. Additionally, enhanced staff training and education is ongoing.
We remain steadfast in our commitment to resolve these issues and to build upon our legacy of providing quality care to this community.”
to view the findings and Plans of Correction.
Children's Hospital of Michigan Surgeon-in-Chief Dr. Joseph Lelli says, "While recent findings have shown areas for additional improvement in our CSP department, I have seen a consistent effort on the part of our DMC team members to ensure that our surgical services continue to be safely delivered with the highest quality of care. I'm encouraged by the changes made thus far and look forward to being a part of the positive efforts moving forward to create a world-class CSP department.”
"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.
Is DMC under investigation by the Michigan Department of Licensing and Regulatory Affairs (LARA) and the Centers for Medicare and Medicaid Services (CMS)?
On August 29 and 30, surveyors from the Centers for Medicare and Medicaid Services (CMS) and the Michigan Department of Licensing and Regulatory Affairs (LARA concluded an onsite survey of DMC’s surgical instrument sterilization process.
Did DMC receive the survey findings/results?
On September 15, we received the results of the survey conducted by LARA and CMS, which included some findings requiring corrective action by the hospital. We have already taken many actions to address the findings, including leadership and structural standardization, improved education, training and competency documentation, improved auditing and event monitoring. This will be documented in our comprehensive plans of correction we will submit to CMS and LARA. Once the authorities have had an opportunity to review and approve our corrective action plan, we will make them public on our DMC.org/OurMessageToTheCommunity. We look forward to working with both agencies to address all findings raised during the survey.
What is DMC doing to address concerns regarding its instrument sterilization process?
We are deeply committed to maintaining the community’s confidence in this important function. Our entire leadership team is focused on taking the necessary steps to improve our efficiencies and processes and to delivering the highest quality of service.
In June 2016, we began outsourcing CSP management to Unity HealthTrust, a highly regarded organization with more than 45 years of experience overseeing CSP functions for companies across the country. Hospital leadership meets regularly with Unity leadership to review progress and address areas of opportunity.
Many changes have already been implemented, including the development of a Perioperative Council and task force, focused on enhancing the sterilization process, improved management and staff education, enhanced communication throughout the process pathway, standardized processes, equipment and supplies, added staff , auditing and verifying instrumentation consistency and ensured all self-reported events are mapped to appropriately inform management of issues.
Are DMC operating rooms still open? What about patients who would like to speak directly with a physician?
Yes, our operating rooms are still open and busy. Any patient who would like to discuss the course of his or her treatment may contact their DMC physician or 888-362-3370.
What should the community know about quality at DMC, in light of recent local news?
Nothing is more important to us that the quality of our services and the trust of our community.
We are proud of our 150 legacy serving the City of Detroit and of the many quality and service awards we have received throughout the years, including U.S. News & World Report’s “America’s Best Hospitals” and “America’s Best Children’s Hospitals,” and The Leapfrog Group’s “Top Hospitals for Safety and Quality.” We believe the community should continue to have confidence in the care they receive at DMC. We also will work diligently to ensure that our actions are sustained. Nothing is more important to us than the safety and quality of the services we provide to our patients. Are the unions working with hospital management? Yes, hospital leadership continues to meet regularly and work collaboratively with our union representatives.
Which DMC hospitals use the CSP unit?
The CSP is located inside Detroit Receiving Hospital and services the hospitals on the DMC midtown campus.
How is DMC sharing information with the public?
We will continue posting updates to our public website www.dmc.org/OurMessageToTheCommunity.
We have been—and continue to be—focused on sharing information internally and with the community, and making operational changes in the spirit of continual improvement. Following the reports from the regulatory agencies, we will share that information on our website.
9.15.16 DMC Today