Let us suppose that you have the ill luck to need surgery. It is not an emergency, so you have time to be prudent.
I do not need surgery. This is hypothetical.
You don’t want to get the down and dirty tales of your local hospital.
You don’t want the horror stories from the neighbor over the back fence.
You want an authoritative snapshot of your hospital’s functioning so you can be prepared to deal with any problem areas.
You want to be a compliant, but well-prepared patient.
So this is what you do.
October 28, 2011 9:17 PM
Email FOIL petition to NYS Department of Health FOIL office requesting information on Millard Fillmore Suburban Hospital. The request is for the two most recent top-bottom inspections of the hospital and also for copies of any Statements of Deficiencies and Plans of Correction issued from 9/17/2009 – Present.
Instructions to file a FOIL petition for this information (under the Freedom of Information Law) is found on the DOH website.
http://hospitals.nyhealth.gov/foil.php
November 1, 2011
Letter dated November 1, 2011 from FOIL office acknowledges receipt of my FOIL petition and warns of possible charges for the public records.
November 21, 2011
Postmark on packet of materials from DOH FOIL office. Enclosed letter was dated November 17, 2011.
Envelope arrives over Thanksgiving. When I examine the packet, I discover that the Statements of Deficiencies show which minimum standards have been found unmet with details that clarify the nature of the deficiency, but that the required Plans of Correction submitted by the hospital to correct the deficiencies are completely redacted. Thus, the public has no way of knowing how the hospital responded and certainly no way of being able to determine how well the hospital has done with correcting the deficiency.
The requested hospital surveys are missing from the packet.
So is a bill for any charges. For which I am grateful.
I have 30 days to respond if I am dissatisfied with the packet.
There is a delay, due to a family death. The death was unexpected and the Kaleida facility where the person died tried to talk the family out of an autopsy. Staff didn’t succeed. Autopsy ordered. Family is very upset. But – the cause is unknown.
December 5, 2011
I phone the DOH FOIL office and leave a message for one of the lawyers to return my call. He returns the call very quickly. He hadn’t noticed the request for the hospital surveys, says I don’t need to make a written request. He will pass the request to the hospital program.
Second call comes from another staff member an hour later. She will handle the request.
December 5, 2011 11:12 AM
Meanwhile, I send an email thank-you to the first lawyer confirming my understanding that I don’t need to make a formal request for the missing documents and thanking him for his rapid response (thus, responding in writing anyway in case this falls through a crack someplace).
December 6, 2011 04:33 PM Email from NYS DOH states that the department does not inspect the hospital. Petitioner should contact The Joint Commission for further information. TJC contact information provided.
December 6, 2011 04:45 PM Phone call to The Joint Commission in Chicago. Ramona says Kaleida is not a TJC accredited hospital. She asks Linda to assist in the search. Ramona says to notice that the TJC gold seal is not on the Kaleida website. She notes that there is an endorsement on the site however. She asks me if I am familiar with Buffalo S-A-B-R-E-S. Perhaps they would be able to provide the information I seek.
I reply that the Buffalo Sabres is our hockey team.
Linda suggests I phone the hospital and ask for their id# if they say they are part of TJC.
December 6, 2011 05:23 PM
Public Notice of a TJC upcoming inspection February 5 – February 11, 2005 on the Millard Fillmore Suburban Hospital website, posted January 5, 2005.
http://suburban.kaleidahealth.org/news/news_display.asp?artID=127
December 6, 2011 05:28 PM
News release, dated 11/3/2008 that TCJ has accredited all of the Kaleida hospitals for a period of three years (the normal accreditation cycle). On the Suburban website.
http://suburban.kaleidahealth.org/news/news_display.asp?artID=1457
December 7, 2011 AM 10:42 AM Renewed search on the Kaleida Health web page turns up “DNV Grants Kaleida Health Accreditation, released 12/13/2010.
http://www.kaleidahealth.org/news/news_display.asp?artID=2582
DNV = Det Norske Veritas
December 7, 2011 10:49 AM Locate Kaleida Health on the list of DNV Accredited Hospitals
http://dnvaccreditation.com/pr/dnv/kaleida-s-bold-approach.aspx
December 7, 2011 AM Search “Det Norsk Veritas” Download document Ref: S&C-09-02, dated October 3, 2008 from the Centers for Medicare and Medicaid Services website. Subject: Approval of Deeming Authority of Det Norske Veritas Healthcare, Inc. for Hospitals.
http://dnvaccreditation.com/pr/dnv/document/cms_deeming_approval_of_dnvhc_tcm4-358496.pdf
OK. So DNV can do hospital inspections to see if hospitals meet the state and federal hospital regulations for minimum care.
December 7, 2011 11:15 (approx) AM Phone DOH FOIL office. Speak to Karen and inform her that the hospital for which I am seeking latest inspection reports is not a TJC hospital, as the DOH had informed me, but rather is a DNV hospital. So now I need the contact information for DNV.
Karen tries unsuccessfully to connect me to the staff member who passed on the incorrect information yesterday. I ask, rather than have FOIL office redirect my message to the office that deals with hospital surveys in the DOH, is there anyone I could talk to in the hospital program to obtain the contact information.
Karen gives me a phone number. She tells me to make sure that I tell the person I have a FOIL petition already. Otherwise, the person will send me right back to the FOIL office (to Karen).
I phone that number. I explain the problem as succinctly as possible. I was given incorrect information re the accreditation agency for Kaleida. Can she provide the correct contact information. And also, they might want to correct their records.
She is surprised. “I’m in charge of the survey requests. No one came to me with this yesterday.”
She looks up the hospital. She has DNV recorded for Kaleida. And – she has the surveys for distribution to inquirers.
She finds my FOIL petition number to verify.
In very short order, she emails me the survey, saying she doesn’t understand why this should be so hard when she has the surveys on hand and can pull them and get them out within five minutes. Rather than send it to the main FOIL office for them to forward to me, she emails it.
December 7, 2011 12:40 PM
I send thank-you note for the survey and say I realize I should have asked for the previous survey as well – which was a TJC survey – since my petition requested the two most recent surveys.
December 7, 2011 13:07 PM
I receive the TJC 2008 survey with a note that says (in part):
… in the spirit of not being too bureaucratic (which is hard for us bureaucrats), I’ve attached [the TJC] survey as requested.
God only knows how many rules this angel has broken, so I am not mentioning her name.
The Surveys make for interesting reading, not particularly salacious reading. I discover that 30 separate entities are listed under the Kaleida system. I find other information that would be useful to know if I were about to enter one of the Kaleida hospitals.
Of course, the surveys are already somewhat stale. The DNV survey was conducted in October 2010, and the next survey was due a couple of months ago.
Still, good to know.
Lessons Learned
There are some pretty decent people at the New York State Department of Health. The responses were all well within the statutory limits, and a couple of people went well beyond the call of duty.
There was no attempt to hide anything or to obfuscate.
Nonetheless, it took quite a long time to obtain information that would be good to know before entering a hospital for an elective procedure. And if the hospital admission was not elective, if the hospital admission was through the emergency department, this information would have arrived long after it would have assisted in preserving the safety of the patient.
There seems to be an issue with Plans of Correction being redacted.
There were no redactions on the hospital surveys from the accrediting agencies. Those surveys included detailed Plans of Correction, including the names of those responsible for administering the plans from the hospital system side. Thus, it should be possible to find out what the outcomes are.
As to the Kaleida facility where the extended family member died? Since it was not a hospital, but rather a rehab placement for him, extensive information is readily available on the DOH site.
http://nursinghomes.nyhealth.gov/
