UPMC transplant center to rectify violations
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The state Health Department appeared to take UPMC Presbyterian Shadyside's world-renowned transplant program to task this week, releasing the results of a report that showed it was not compliant with federal regulations in 30 areas.
After a four-day inspection by 14 state inspectors in March, the report found documentation problems with everything from failure to inform people of their patient rights, to not documenting that blood compatibility matches were done before a transplant, to not properly counting everyone who died from a transplant-related death.
The report was done at the request of the federal Centers for Medicare and Medicaid Services.
But UPMC officials Thursday said the findings in the lengthy, 62-page report were really nothing more than easily resolved differences over paperwork.
"We recognize the importance of these types of reviews. The overall point of this is to improve transplant quality," said Dr. Abhinav Humar, UPMC's transplant chief. "It's not that we aren't documenting these issues. It's just not quite as they'd like it to be."
Some of the violations sound worse than they are, Dr. Humar said.
For example, inspectors checked UPMC's records and interviewed staff about whether the hospital made sure donor and recipient's blood types were compatible during 24 recent transplants, and "it was determined the center failed to ensure that the program's organ recovery team obtained, reviewed and compared the deceased donor's blood type and donor identification with the intended recipient's blood type on site, prior to the organ recovery taking place ... ," according to the report.
But Dr. Humar said the state wanted two people -- a surgeon and another health care professional, like a nurse -- signing a document that verified that the blood types were checked. At UPMC, they had a form, but it only had room for one signature, not two, Dr. Humar said.
"The important thing to remember here is that never in our history have we ever inserted an organ from a wrong blood-type donor," he said.
Still, Dr. Humar said, the way the report reads sounds pretty bad.
"When it gets reported a certain way it looks very damming and very harmful because it alarms patients, who wonder, 'Oh, what are they trying to do there?' " he said.
UPMC got the report on April 8 and should have all of the violations resolved by next week, with all the new forms and policies in place, said Deborah Maurer, UPMC's transplant administrator.
The inspection comes under new rules implemented three years ago by CMS that calls for such inspections every three years. If a transplant center is found to have "condition-level" violations -- of which UPMC had three -- it has to correct them within 180 days of receiving the report or it could lose Medicare reimbursement.
Although there are no allegations that any patients were directly harmed because of the violations, CMS sees the report as more than just a paperwork issue.
"Ultimately, this is about making sure patients have all the services they're entitled to," said Lorraine Ryan, a CMS spokeswoman from its Philadelphia office. "It all goes to the heart of patient safety. That's why we have rules."
First Published May 7, 2010 12:00 am
