Dateline: Redding California, 2002 – A jetliner carrying 700 passengers crashed into Mount Shasta killing 69 and injuring most of the remainder. Pilot error caused the crash. The FAA ignored the incident.
If this story were true, we would be outraged and demand a full government investigation of the FAA’s negligent failure to investigate. Yet the story is partially true: all the “passengers” were patients at Redding Medical Center in Redding, California between 1993 and 2002. The two “pilots” were Drs. Fidel Realyvasquez, a cardiac surgeon, and Chae Moon, a self-proclaimed cardiologist.
In late 2002, the FBI “busted” this conspiracy of negligence. The two physicians have lost their license to practice in California. The hospital administrators who helped hide the doctors from public scrutiny have relocated to foreign countries to find work.
But “busting” the “bad guys” for unnecessary heart procedures and surgery on healthy patients was not good enough for my team, or for the people, so we set out to discover how this gross and near criminal medical negligence could possibly be tolerated for 10 years at a well respected, accredited, and licensed hospital.
Based on our investigation and report gleaned from public documents and private testimony, we found that government officials failed to enforce our laws: laws necessary to assure hospitals are safe for the public.
Both State and federal health care officials knew as early as 1999 that RMC and its medical staff could not assure patient safety for cardiac services. These officials knew the hospital and medical staff provided no oversight or review of the quality of care provided by Moon and RV. In fact, both of these physicians were in charge of their own reviews. Moreover, our main hospital accreditation organization, the Joint Commission, also knew in 1999 of the danger Moon and RV posed to patients because their patient care services were hidden from review by their peers. The JC accredited RMC anyway. The first peer review provided for Moon and RV was performed by outside medical experts hired by the FBI in 2002.
Now that we know hospital peer review requirements are not enforced, the California legislature refuses to give our enforcement agency, Licensing and Certification, the power it needs to enforce our laws.
Professional stakeholders, but not the public, oppose law enforcement penalties that would compel effective peer review. L&C does have the power to impose fines of $50,000 to $100,000 against hospitals for allowing imminent danger to patients. But the absence of peer review is not an imminent danger, even though hundreds of patients can be harmed over time. Patients at many California hospitals are vulnerable to unmitigated medical negligence which can only be prevented by brave conscientious physicians who have the professional courage to voluntarily identify physicians who allegedly endanger patients and hold them accountable through the peer review process. In hospitals where peer review is absent or ineffective, there is no mechanism to cull out negligent physicians until after many patients are damaged.
When peer review is properly performed, suspected physician errors are discovered timely, through analysis of various triggers, such as unexpected return to the operating room or unexpected blood loss. Promoted by these triggers, specific patient cases are reviewed by other physicians at the same hospital. The care provided may be acceptable or problematic. If physician negligence is discovered, corrective action is taken. A physician may be instructed to take more education, limit performance of certain services, or could be discharged from the medical staff for egregious acts. The result is safer care for future patients.
The California Legislature ordered a report on California peer review and hired Lumetra, a private company to write it. Lumetra published its report in 2008. Lumetra found that peer review in California is unacceptable, inadequate, and ineffective: patient safety cannot be assured. RMC is the “poster child” for what goes wrong too often. Now, seven years after the FBI “busted” Moon and RV, and after the Department of Justice and CMS kicked RMC out of the Medicare Program, our peer review laws remain unenforced throughout California.
In the 2009 legislative session, the California Legislature has taken up the peer review issue (SB 58, SB 700, AB 120, AB 245, and AB 834). But current proposals will not enact penalties L&C requires to enforce our laws. Experts believe L&C needs the power to impose intermediate sanctions against hospitals and medical staffs for repeat failure to conduct peer review. Currently, the only power L&C has is to revoke the license of the entire hospital, which the Agency rarely does. By contrast, intermediate sanctions could remove the license of a hospital for certain elective services only in those clinical departments (e.g. cardiac services) where peer review is not provided or is ineffective on repeat audit. With this power, a negligent hospital and medical staff would face huge financial losses and, therefore, would provide the missing peer review immediately. Without the enforcement power of intermediate sanctions, hospitals and medical staffs can continue to flaunt our laws knowing the State has no power to enforce them.
In other words, currently peer review is self-administered, not audited for effectiveness, and when not done, there is no power to enforce the requirement. Self-administered peer review in hospitals works as well as self-administered regulation compliance did on Wall Street in 2008. Doctors who need help are not identified, and future patients continue to suffer the consequences.
In 2009, patient safety will remain a goal, not a reality; except, perhaps, in a few self-proclaimed centers of quality. To change this unacceptable situation, you must write to your California legislator and demand enactment of intermediate sanctions to enforce the peer review laws in California.
Good luck next time you are admitted to a hospital in California. You will need it because patient safety cannot be assured. It is safer to fly.
Dr. Rogan is a family and emergency physician who served as the Medicare Medical Director in California from 1997-2003. In 2002, he assisted law enforcement with the RMC investigation. Currently, he is an
independent consultant to health services companies.