University of Virginia Library

I. INTRODUCTION

The Special Committee to Review the Processes and Operations of the University of Virginia Medical Center, appointed by the Rector at the Board of Visitors' meeting on October 10, 1998, has completed its review. The committee was asked to investigate and review hospital procedures as they relate to the "baby switching" incident of 1995 and the two "morgue" incidents which occurred in 1996 and 1998 (see the attached statement by the Rector from the minutes of the Board.)

The committee undertook to fulfill its charge by:

• 1. learning what had occurred;
• 2. understanding the probability of each occurrence;
• 3. understanding hospital procedures in each area related to the occurrences;
• 4. learning what in-house changes were made as a result of each occurrence; and 5. generating recommendations for changes in each area of concern.

After a thorough initial briefing and review of written reports, the committee decided to review management accountability at all levels. The committee was especially interested in the timeliness of the communication and documentation of any procedural shortfalls, as well as corrective action taken to ensure that adverse incidents would not reoccur. The committee did not conduct extensive surveys of, for example, individual patient records or daily operations over a period of time, because the Virginia Department of Health and the Joint Commission for the Accreditation of Healthcare Organizations were already doing so. Nor was its purpose to replicate investigations conducted by the University Police and the Virginia State Police.

The committee was initially briefed on each incident by the Director of Risk Management, Abraham Segres, and the Director of Quality Programs, Christine Matt. Members of the committee and the Director of Audits toured the Medical Center's Labor and Delivery Department and Morgue to view their operations, and the Chair made tours of departments at hospitals elsewhere in Virginia. At its first meeting the committee received four reports that had been generated by various Medical Center departments in response to the Labor and Delivery and Morgue incidents:

• 1. An Internal "Root Cause" analysis of the baby switch, prepared by a Quality Review team led by Ms. Matt, as specified by Medical Center policy and JCAHO rules;
• 2. The initial Risk Management summary of the Morgue incidents;
• 3. An internal Process Improvement report on the Morgue incidents, prepared by
• the Medical Center's Director of Operations Improvement;
• 4. the Ad Hoc Infant Safety and Security Task Force Report.

---

1

These reports gave an overview of what happened, what could have happened, and what might have happened if existing procedures were followed. The first two reports showed the Committee members the accountability trail that existed at the time of each incident's occurrence. These two reports made an attempt to reconstruct the events in order to make some sense out of how a "switch" could in fact have happened.

The third report, "Internal Process Improvement," advised the committee of procedural changes the staff had either implemented or was in the process of implementing to further safeguard patient care. These changes are listed in Section II of this report.

The fourth report, from the Ad Hoc Infant Safety and Security Task Force, presented the Committee with information concerning the identification process for newborn infants, as well as a complete overview of security systems not only on the Labor and Delivery floor, but also throughout the hospital. The Task Force was charged "with designing a comprehensive infant protection system," which would put the Medical Center on the cutting edge of hospital security. The improvements the Task Force has initiated to date are listed in Section II below.

After reviewing the in-house reports, the committee felt confident that Medical Center administrators were committed to understanding how the incidents occurred and were unified in their search for more stringent procedures to prevent any recurrence.

There were two external reports not completed within our committee's investigative time frame. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) report has still not been received by the University. The Virginia Department of Health's final report, dated January 11, 1999 and received by the University January 18, 1999, was generated after a six (6) week on-site survey of the Medical Center that ended on September 20, 1998. (The report was distributed to the committee on Monday, January 25, 1999.) The Department of Health was charged by the federal Healthcare Financing Administration (HCFA) with investigating the Labor and Delivery and Morgue incidents in relation to the Medical Center's ability to comply with Medicare "conditions of participation." Its report found the Medical Center to be out of compliance with Medicare requirements, because of a lack of documented procedures and certain inconsistencies in patient care in Labor and Delivery and the Morgue. Medical Center management is now preparing its plan of correction in response to the Department of Health report. Copies of the response will be provided to the committee and the Board. Because the Department of Health completed its survey at the Medical Center in mid-September, 1998, it was unaware of, and could not take into consideration, the positive changes since implemented by Medical Center administration. Many of these changes directly address the noncompliance issues raised in the report. Nonetheless, the committee is concerned about the allegations in the Department of Health's report, and requests that the Rector allow the committee to remain intact until such time as the committee members are satisfied that the University has complied with all Medicare regulations.

---

2