Focus shifts to fixing kidney program’s faults

By Marshall Allen

Tuesday, Nov. 4, 2008 | 2 a.m.

The intense appeals to save University Medical Center’s kidney transplant program from losing its Medicare funding have overshadowed fundamental patient safety problems revealed by inspectors.

Hospital Chief Executive Kathy Silver acknowledged failures in management of the program, even as she argued that it should remain open.

“I’ll be the first to admit that over the years not enough resources have been applied to this program,” Silver said.

Medicare surveys in March and August found that UMC failed to meet its conditions of funding because of too many patient deaths and other concerns connected to the transplant program. On Friday the federal agency postponed its process of taking away UMC’s funding on the condition that UMC radically reform the program to improve patient safety.

Appeals for leniency for UMC did not mention that the kidney transplant center has more than twice the expected death rate and dozens of recent failures to meet announced standards of patient care.

The primary argument for leniency for the transplant program hinged on a suicide included in the tally of patient deaths. Medicare counts transplant recipient deaths over a 30-month period to determine whether a hospital is meeting its standards.

UMC had five deaths in the time period, including the suicide, and hospital officials say they would have been within Medicare guidelines if there had been only four.

Medicare officials say it’s ridiculous for a hospital to pluck out the numbers it doesn’t like, but that’s been the straw grasped by UMC and its advocates who dismissed the suicide as out of the transplant program’s control.

But that leaves out important context, including that a hospital social worker did not meet with the patient after the surgery, as Medicare requires. The patient committed suicide days after a May 2005 transplant, Medicare officials said.

Silver said UMC did a pre-surgical psychological assessment of the patient who committed suicide, and there was no indication of any problem.

“We felt that including that one death threw us out of compliance, and that this death should not have been included in the number,” Silver said.

Medicare, however, found that UMC was lax in warning patients about the psychological risks of transplants.

Specifically, the March Medicare inspection found that in each of 15 cases reviewed, UMC failed to document that patients were informed of the psychosocial risks of a transplant.

The inspection also said that in all seven cases reviewed there was no participation by a social worker. The social worker told Medicare inspectors that she did not know she should be involved in a patient’s care through the transplant and discharge phases of the procedure.

UMC’s transplant program had a host of other problems that were identified by Medicare during the March inspection. Among the dozens of deficiencies and four overarching failures to meet conditions of participation in Medicare:

• UMC failed to follow its established criteria to determine the suitability of living donors. One donor had a body mass index of 32, which is considered obese, and there is no documentation that explains the rationale for UMC deviating from its established standards.

• UMC failed to complete the verification of compatibility of donor and recipient blood type during organ recovery, after an organ’s arrival at the center and before transplantation in all four living donor medical records and all seven recipient records reviewed.

• UMC failed to develop, implement and maintain a quality assessment/performance improvement program to evaluate its performance.

UMC became the only transplant option in the state after Sunrise Hospital & Medical Center shuttered its program in May. The Sunrise program was also about to have its Medicare funding taken away because of too many patient deaths, records show. But rather than correct its problems, Sunrise decided to merge with UMC.

Both UMC and Sunrise blamed their poor performance on the low number of patients who receive transplants, depriving the hospitals of sufficient revenue to develop the program. Still, UMC was generating income from the program. From June 2007 to June 2008, the program made a net profit of $202,000.

Officials of both hospitals also argued that because their programs had so few patients, even one death dropped their percentages below what’s required for Medicare compliance.

These low-number arguments belie the fact that many like-sized or smaller programs in other states have high patient survival rates. For example, transplant programs in New Mexico and North and South Dakota are similar in volume to UMC but much better in terms of performance.

A Las Vegas performance improvement expert, who would speak only on the condition of that his name not be published, said it appears that UMC mismanaged the kidney transplant program. The hospital knew the rules for being reimbursed by Medicare, but it failed to live up to them, he said.

“I’m not really sure Medicare is being too hard on UMC,” the expert said. “They’re just holding their feet to the fire.”

By Monday, UMC will have to improve its surgical capabilities, prove it has an effective quality assessment/performance improvement program and ensure there will be proper administration of the program. UMC will then be required to pass an unannounced inspection in the coming months to regain its certification.

The temporary reprieve is a victory for the hospital officials, congressional delegates and transplant advocates who lobbied against Medicare’s plan to take away the hospital’s funding. Closing UMC’s kidney transplant program would mean the 200 people on the waiting list would have to travel hundreds of miles for treatment.

“It is critical that individuals who need an organ transplant get good quality of care,” said Thomas Hamilton, director of Medicare’s survey and certification group. “If that means that individuals need to travel a little bit further to get good quality of care, then we think that is a trade-off that should be made.”

The political appeals for leniency included a letter and personal conversations with the head of Medicare by Rep. Shelly Berkley, D-Las Vegas, and Republican Reps. Jon Porter and Dean Heller.

Berkley’s husband, Dr. Larry Lehrner, is a partner at Kidney Specialists of Southern Nevada, which has a $588,200 annual contract to provide nephrology services at UMC, which includes the kidney transplant program. UMC officials said Lehrner handles the business aspects of the contract, not the medical services.

Officials from Citizens for Responsibility and Ethics in Washington said they do not consider Berkley’s advocacy for UMC a conflict of interest because Lehrner does not have a direct financial tie to Medicare.