Recovery in works at Md. General

Peggy Dowdy wasn't sure whether to trust the place. Maryland General Hospital workers had sent out hundreds of HIV and hepatitis test results that they knew might be wrong. As she met in April with her new doctor in a hospital office building, last year's laboratory scandal weighed on her mind.

The West Baltimore resident wondered whether the doctor would act responsibly as he diagnosed her nosebleeds, the ringing in her ears, the numbness in her arms.

But Dr. Agha Khan was kind, and Dowdy was reassured.

"I heard in the news about the blood thing, the HIV thing," Dowdy said as she left her appointment with Khan. "I was thinking, 'Oh, my God. They're going to cut me open and make a mistake on me.

"But he put me right at ease."

Sixteen months after the lab breakdown scared away patients, they are coming back to Maryland General. One at a time, the hospital that has served West Baltimore's ailing poor for more than a century seeks to persuade them that it is still worthy.

As it deals with the distrust generated by the lab, Maryland General also confronts deeper problems. From at least the mid-1990s until spring 2004, the hospital's board and a changing cast of top executives failed to act quickly as oversight systems designed to protect patients failed, according to The Sun's review of regulatory documents, accreditation reports, lawsuits and internal hospital letters, as well as interviews. The oversight breakdowns, The Sun found, sometimes had deadly consequences.

But now, since the lab scandal, the University of Maryland Medical System, which oversees the hospital, has pushed ahead with an ambitious plan. It wants to turn the urban hospital that serves about 12,000 inpatients a year, most of them uninsured, into a national model.

"Our objective," said system Chief Executive Officer Edmond F. Notebaert, "is to restore it to what it ought to be, make it an urban success story."

Overhauling, oursourcing

The University of Maryland Medical System has taken a comprehensive approach, overhauling hospital management, outsourcing entire departments and instituting ways to monitor quality and hold its executives, physicians and nurses accountable.

It is too soon to tell whether the moves are working. But a barometer of their early progress can be found in physicians such as Khan.

Though he is Maryland General's chief of neurosurgery, Khan said he had cut back his practice at the hospital over the past several years amid concern that management lapses, like those that finally surfaced in the lab, made it dangerous to perform complex operations there. But with the recent changes, including a promised unit for special care of stroke victims and neurosurgery patients, Khan is handling more cases at Maryland General.

Something about its possibilities, and its sometimes desperately needy patients, made him stay, even as the hospital descended into a nightmare of its own making.

"This is an area that needs help," Khan said of Maryland General's neighborhood, "and this is where resurrection is going to occur."

Notebaert and other system officials say some of the improvements under way began before the lab scandal, and they dispute that Maryland General had systemic problems. It has been, Notebaert said, a "fundamentally good hospital."

Even elite institutions experience harmful medical errors. But at Maryland General, oversight systems every hospital must have to ensure proper care broke down repeatedly. Interviews, public records and internal hospital documents show that the hospital was particularly lax in dealing with issues of physician competency.

Among the doctors who received and retained practicing privileges were an anesthesiologist who was asked to resign from his previous hospital after the death of a patient, and physicians who had been sued more than a dozen times, including a neurosurgeon who had been sued at least 19 times.

Residents in the hospital's obstetrics department did not have proper around-the-clock supervision, Maryland General's former insurer said in 2002, while half its anesthesiology department was made up of doctors who were not board certified, meaning they had not passed a major test of expertise in their specialty.

Maryland General's insurer tried to cancel the hospital's policy effective January 2002. A key reason, the company said later, was an "overall increase in professional liability suits/claims arising out of direct negligence" by staff and doctors.

The OHIC Insurance Co. identified a managerial breakdown: Hospital officials repeatedly failed to screen out problem physicians and didn't seem to know that Maryland General's attorney had missed court deadlines, failed to file important documents or simply didn't show up in court.

Lab trouble arose last year

Early last year, state regulators also uncovered the hospital's failure to provide proper oversight in the lab. Maryland General's board, the regulators said, didn't ensure that the institution had "an effective, hospital-wide quality assurance and performance improvement program and failed to provide adequate oversight of laboratory services."

The problems were playing out in an institution long critical to the health of its diverse community.

Maryland General was founded in 1881 as a training facility for Baltimore Medical College. It has struggled often, remaining at Linden Avenue and West Madison Street to serve the poor as Baltimore's population declined, bill payers tightened reimbursement, and at least eight other city hospitals closed, merged or fled to the suburbs.

Today, drug addicts shoot up not far from where classical music lovers stroll to the Meyerhoff Symphony Hall.

The symphony-goers rarely come to the nearby hospital. The drug addicts do.

Maryland General's methadone clinic helps them fight off heroin addiction. Its HIV specialists treat current and former drug users battling for their lives.

More than a third of its inpatients live within a radius of about three miles. They are born in the hospital, and they die there; in between, they have babies, back surgeries and heart checkups. They are cared for in part by a core of longtime physicians who remained for decades even as other doctors - and entire hospitals - fled the city.

Those who stayed labor without glory at a hospital located anonymously between two of the world's best - Johns Hopkins Hospital to the east and the University of Maryland Medical Center to the west.

About 470 physicians have privileges at Maryland General, state records show, though a smaller number practice there regularly. The hospital is required by the Joint Commission on Accreditation of Healthcare Organizations, the major standard-setting and accrediting group, to have a system for checking physicians' credentials and competency.

Despite the requirements, the hospital had repeatedly allowed doctors with questionable records to practice, or gave them broader privileges than their training might have warranted.

The Joint Commission found shortcomings in credentialing in a November 2002 inspection and again in January 2004. The hospital, the commission said last year, wasn't adequately investigating practitioners' performances when it came time to renew their privileges.

Such failures weren't just matters of recordkeeping: Over the years, patients repeatedly alleged that they were harmed by physicians who had questionable records.

Lawsuits for surgeon

Among several egregious examples was Dr. Henry A. Saiontz. Florida Department of Financial Services records show that the neurosurgeon had been sued 19 times for malpractice in that state by early 1995, when Maryland General granted him privileges. By then, records show, there had been payouts in eight of those cases totaling $1.73 million.

Saiontz voluntarily relinquished his Florida medical license in March 1998 rather than face disciplinary proceedings there, leading the Maryland Board of Physicians to put him on probation the same year and order him to quit performing surgeries.

The board licenses physicians and can investigate when they're alleged to have given substandard care. A peer review is conducted by physicians with relevant expertise, and it can lead to board sanctions as serious as license revocation.

Doctors accused of violations sometimes agree to settlements known as consent orders.

Before the board curtailed his surgical practice, Saiontz performed three operations at Maryland General that resulted in lawsuits, later settled, by patients claiming to be injured.

"If they hadn't hired him, I wouldn't be like this," said Dawn Rexrode Schabowsky of Glen Burnie, 45, who is among those who sued and then settled. She walks with a halting gait and uses a cane - the result, she said, of Saiontz's 1997 surgery on her neck.

She remains angry at Maryland General for giving Saiontz privileges and at a physicians' practice for employing him.

Saiontz, who described himself as "retired from the active practice of medicine," said lawsuit settlements aren't a fair way to judge competence.

"The insurance companies settle, and you have no choice," Saiontz said. "I was an early victim of the malpractice crisis."

In 1998, the same year the physicians board took action against Saiontz, it received a complaint about another Maryland General physician and launched an investigation.

Dr. Daniel R. Howard was a family practitioner who gave prenatal care to adolescents at Maryland General's clinic in the Laurence G. Paquin School and delivered their babies at the hospital. He did so even though the licensing information he provided to the Board of Physicians indicates that he had not concentrated his training in obstetrics and wasn't board certified in it.

Howard allowed a 13-year-old girl to continue in labor for 22 hours in May 1998, didn't properly react as her baby's heart raced past 190 beats per minute and then drastically slowed, and used vacuum suction for "an excessive period" when the boy got caught in the mother's narrow pelvis, according to a Board of Physicians charging document, which did not name the girl.

The newborn died. Howard later admitted to the findings in a consent order.

Then came the case of expectant mother Kitara A. Abdulbaqi, 17. She died in November 1998 after Howard allegedly failed to diagnose - from her weight gain, along with blood and protein noted in her urine - that she had a condition known as preeclampsia that could lead to a seizure and death, according to a complaint filed by the girl's guardian in the state's Health Claims Arbitration Office. The complaint was transferred to Baltimore City Circuit Court, where a court record shows it was settled before trial, then sealed.

The board charged him with failure to meet standards of care and highlighted four cases, including the 13-year-old's. Howard promised as part of his consent order with the board to stop practicing obstetrics for the rest of his career beginning in May 2001. It did not curtail his ability to practice in other areas.

Board records indicate that he retains privileges at Maryland General. The hospital's Web site lists his specialties as family practice and emergency medicine. He declined to comment.

Dr. Glenn Robbins, the University of Maryland Medical System's chief medical officer, said Howard's board certification in family practice previously qualified him to deliver babies. The American Board of Family Practice revoked that certification in April 2001.

Errors by anesthesiologist

One physician who worked at Maryland General was disciplined in May. The Board of Physicians revoked the medical license of Dr. Carlos A. Almeida after finding that the anesthesiologist repeatedly failed to meet medical standards while caring for patients, including three people who died - two of them at Maryland General.

The hospital granted Almeida privileges in the spring of 1998, several months after Almeida resigned his privileges at St. Mary's Hospital in Leonardtown rather than have them suspended, Board of Physicians' findings show.

Almeida admitted to the board in a 1999 consent order that he had not met medical standards in four cases at St. Mary's, including by failing to properly assess or monitor a 78-year-old man who died. The board put him on probation, but he continued to work at Maryland General.

"In addition to his inability to perform routine tasks such as adequately assessing patients preoperatively," the board's peer reviewers found, "he fails to recognize when a potential problem might occur and take appropriate steps to prevent it."

In May 2000, a 54-year-old man in Almeida's care had a heart attack during elective surgery and died. Almeida, the board later found, had not adequately examined the man or his medical records to determine if he could tolerate anesthesia, and he administered medicines known to depress heart rate after the man went into cardiac arrest.

The next year, William Purdie, 58, of Baltimore, died after a spine surgery during which Almeida was responsible for monitoring vital signs and fluids. After the 11-hour operation, Almeida dutifully told Purdie's surgeon that the patient had lost about 3.6 liters of blood, the surgeon wrote in an internal hospital letter July 25, 2001. Surgeon Gary Dix wrote that he was "shocked" to learn that Almeida had not replaced a drop.

Purdie died soon afterward. Maryland General suspended Almeida's hospital privileges shortly after that.

Almeida didn't return calls or respond to a certified letter.

Problems peaked in 2001

As it turned out, oversight problems were coming to a head in numerous areas of the hospital in 2001, the year Purdie died.

Nurses and doctors were deeply concerned about the anesthesiology department. Laboratory workers criticized the judgment of their bosses. The hospital's new executive in charge of managing liability risks struggled to assess the breadth of the hospital's legal woes. Its insurer's patience was wearing thin.

Khan, Maryland General's head of neurological surgery, was so concerned about the depth of the hospital's problems that he fired off a warning letter July 27, 2001, to Dr. John Manzari, the hospital's senior vice president of medical affairs.

"The situation of Mr. Purdie's case makes it extremely difficult for us to continue to do complicated cases, as we hope to do to advance neurosurgery at Maryland General Hospital," he wrote after Almeida's patient died.

The hospital, Khan said, needed a group in anesthesiology focused on neurosurgical patients.

In the cramped laboratory next to the hospital's main tower, Teresa Williams said the two divisions for which she had lead lab tech duties were in "total chaos" in January 2001.

"The department," she recounted in a subsequent letter to then-state Secretary of Health Nelson J. Sabatini, Rep. Elijah E. Cummings and others, "was poorly staffed, poorly trained, overworked and morale was low. We all were totally overwhelmed."

Inside the hospital's risk management offices, Susan Longley made a discovery as she pored over medical malpractice cases in February 2001, a Maryland Insurance Administration hearing transcript shows. Longley, the hospital's new risk management director, said she found that Maryland General's outside attorney had "in my opinion committed legal malpractice in one of our medical malpractice case[s]."

Attorney Patti D. Gilman West "misrepresented the status" of one case to the hospital and failed "to reasonably communicate with her client about the status" of another as she battled a serious bone infection, according to a Maryland Court of Appeals decision indefinitely suspending her from the practice of law.

The 2003 decision said she missed deadlines and failed to appear in court, forcing the hospital to settle cases. She couldn't be reached.

Notebaert, the head of the system, said he was unfamiliar with earlier malpractice cases because they came before he took his job in the fall of 2003. He also noted that a number of the cases had not been properly defended and might have turned out differently if they had been.

"Having a lawsuit against you does not mean you did something wrong," Notebaert said.

But the lawsuits against Maryland General and its doctors worried James M. Baldyga, an executive at the OHIC Insurance Co., the hospital's insurer.

In a January 2002 letter to his company's attorney, he listed a series of problems stretching from the hospital's poor system for screening and reviewing doctors' competency to a lack of 24-hour oversight of obstetrics and gynecology residents. Hospital managers, he said, ignored the insurer's recommendations.

The OHIC was losing money on Maryland General. It had collected premiums of nearly $9.1 million since it began insuring the hospital in 1985, but it had paid out $13.1 million. When the amount of money it was reserving for Maryland General's potential future losses was included, the OHIC's losses on the account during the period totaled $16.5 million.

As Baldyga wrote his letter in January 2002, the OHIC was reserving $2.3 million in case it had to pay out on any of the 10 open cases involving alleged negligence in Maryland General's obstetrics department. Several cases had arisen from a single doctor, "an employed family practitioner treating and handling deliveries for OB/GYN patients on a regular basis," Baldyga wrote without naming the doctor. "This went on for several years."

The OHIC succeeded in ending its relationship with Maryland General. The hospital is now self-insured as part of the medical system, meaning the system sets aside funds to protect against losses.

Medical system officials don't dispute the seriousness of the lab's problems. On the question of how long it took the hospital to pull the privileges of problem physicians, Notebaert said, "You can judge the timeliness issue and draw your own conclusions."

But they strongly disagree about the scope of the hospital's problems.

Robbins, the medical system's chief medical officer, said in a letter to The Sun in December that "we know of no evidence - nor have you presented any to us outside of your own review of select, unrelated events at the hospital - that suggests that there are or was a pattern of quality problems at MGH."

Maryland General came under the medical system's authority in 1999, when it joined the system. But under an affiliation agreement, the system promised not to change the hospital's management for three years, Notebaert explained. The move was intended in part to ease concerns of some of Maryland General's staff.

When the transition period expired in 2002, the medical system didn't immediately assert itself. Problems persisted, surfacing in the lab.

Overriding of controls

Regulators found in 2004 that employees had overridden quality controls to send out lab test results. The problems were brought to light only after the state investigated allegations by whistleblowers in the lab, who said they had complained unsuccessfully to their bosses for more than a year about questionable practices for reporting test results and other concerns.

The complaints, and the subsequent findings by the state's Office of Health Care Quality, led to congressional hearings, state and federal legislation to strengthen lab oversight, a state Medicaid fraud billing investigation and a probe by the Health and Human Services Department's Office of Inspector General. The system says that the federal investigation has since been closed without action, and that it expects resolution soon of a separate federal whistleblowers' suit and the state investigation.

Notebaert, who had become the system's CEO in September 2003, said it was months before he knew of the lab breakdown. He said he found out about it in March 2004, as he was sitting in his eighth-floor Pratt Street office talking on the phone with Maryland General CEO Timothy D. Miller.

Notebaert said he reacted immediately, dispatching his top troubleshooter to get to the bottom of what was going on. Maryland General offered free retesting, which showed that the majority of the initial test results were correct. Within weeks, Miller had resigned. He did not return calls or respond to a certified letter seeking comment.

"I can tell you I believe the issues happening in the lab were not singularly related to the lab supervision, and that the chain of accountability needed to be improved," Notebaert said in an interview. "Any CEO needs to monitor and oversee and also cross-check. But you don't delegate and ignore."

More changes quickly followed. Others were launched later.

Replacing executives

In addition to replacing Miller last August with Colene Y. Daniel, a former Johns Hopkins Health System vice president, the medical system named Robbins, an executive with expertise in measuring hospital quality, to replace the retiring Manzari as Maryland General's acting senior vice president of medical affairs. It has since named a permanent replacement: Dr. Mohamed S. Al-Ibrahim, formerly executive chief of staff with the Veterans Affairs Maryland Health Care System.

Daniel, 51, is much more visible in the hospital than her predecessor, some physicians say. A Baltimore City school board member from 1997 to 2003, she has worked both as a hospital housekeeper - while in college - and as associate director of the 621-bed University of Chicago Hospitals.

Last fall, accompanied by a reporter, she stopped during her regular hospital rounds to hug a pediatrician, listen to a neurosurgeon's hopes for a new hospital building and take in a radiologist's enthusiasm about software that enables patients' CT scans to be viewed by computer from afar.

"You look so sad this morning," she said as she passed another employee. "What's up?"

To help track activity at Maryland General, Daniel and the system launched a quality improvement committee made up of hospital executives and clinical leaders. It conducts quarterly audits of each department. The idea is partly to "provide improved clinical oversight by the medical staff," Robbins said in a May letter to The Sun.

The hospital has also instituted a quarterly physician report card to evaluate each doctor's performance and now requires its new physicians to be board-certified in their specialties within five years of finishing their residencies.

Some of the changes preceded the laboratory problems, but the focus on quality has been stepped up appreciably since then. For example, the hospital has just introduced software to measure quality of care, using billing data that tracks every service patients use.

The software can compare, say, the complication rates of heart patients admitted through its emergency room with the complication rates of patients at other hospitals admitted the same way. In one use of the software, Maryland General found that last year's mortality and complication rates were lower than would be expected for a hospital with its mix of patient ailments, Robbins said this month.

Later, the software might also be used to measure the relative mortality rates and complication rates of patients seen by various physicians, giving the hospital another way to measure doctors' performance.

"One of my goals with this system is to have real, physician-specific data that's actually valid," Robbins said in an interview. "Not only physicians, but nursing units - things like that: How are they functioning on an outcome basis?"

Outside expertise is hired

The hospital also brought outside expertise to a number of departments.

Sunrise, Fla.-based Sheridan Healthcare began managing the anesthesiology department in March 2004. It hires only doctors who have completed an anesthesiology residency and are either board certified or board eligible, meaning they either have taken a rigorous test to prove their competency in the specialty or are eligible to take the test.

Last fall, the hospital contracted with the University of Maryland Medical School's Department of Emergency Medicine to operate its emergency department. It discontinued its obstetrics/gynecology residency program in July 2004, shortly after it lost its accreditation.

Judging how far the hospital has come since spring 2004 is difficult. The system has limited The Sun's access inside Maryland General, allowing a reporter on patient floors only once, last fall.

Robbins said great progress has been made, though he said the improvements represent an effort to "build on the hospital's performance" that began before the lab scandal.

"For the past year, physician leadership, management and employee efforts have been focused on two areas: quality and operational excellence," Robbins wrote The Sun in May. "Maryland General has made huge strides in both areas."

The hospital's figures show it is now attracting about as many inpatients as it did before the laboratory scandal, which drove many away. Maryland General is seeking to nurture loyalty by deepening connections with the largely African-American neighborhood it nearly left in the 1980s for a new home in Cockeysville.

The hospital has started a marketing campaign, updated its Web site with diverse faces, and named an external affairs director to strengthen ties with community organizations.

Daniel must pursue the multipronged strategy, including melding the offerings of a top notch academic medical center with the community hospital, while continuing to carefully cultivate a core of longtime Maryland General physicians.

She has been well-received by a number of doctors, among them Khan, the head of neurosurgery. The doctor who once cut back his Maryland General practice is operating more often there.

The changes were evident in April as Khan saw patients in the Maryland General Professional Building across from the hospital.

Patient Dixie Whitcomb, 43, of Timonium, in tears from the pain radiating down her neck and right arm, told Khan she had learned about him from a Maryland General advertisement. He ordered tests to confirm his diagnosis of pinched nerves, then referred her to a newly recruited Maryland General physician for pain management - a specialty the hospital had not had just months ago.

Whitcomb left relieved. "I'm glad I finally found somebody to help me," she said.

This past spring, as Khan steered his BMW through downtown Baltimore toward Maryland General, he pointed hopefully to the nearby Symphony Center apartment and office complex. Maryland General, he said, could be transformed, as the area o improves, into a downtown "boutique" hospital frequented by the affluent as well as the poor.

"I think the hospital has a great future under new leadership," he said. "In a few years, you will see a totally different Maryland General Hospital."