A CNN investigation, a closed heart surgery program, a resigned CEO: What happened at St. Mary's Medical Center?

St. Mary's Medical Center in West Palm Beach, Fla., is in the center of a significant storm involving the national media, its executive leadership and — most importantly — patient safety.

A chain of events has unfolded since CNN aired a story June 1 about the 464-bed hospital's pediatric cardiothoracic surgery program and its mortality rate. In the latest development, St. Mary's CEO David Carbone resigned from his position Wednesday after nine years in the role.

His departure came two days after the hospital announced permanent closure of the surgery program. St. Mary's blamed "inaccurate media reports" for the program's closure, saying the reports made it "significantly more challenging to build a sustainable volume."

Here are 14 things to know about the chain of events.

1. CNN broadcasted the story about St. Mary's Medical Center June 1 and published subsequent stories online based on a yearlong investigation into the hospital. CNN reported at least nine babies died after having heart surgery at the hospital since 2011, when its pediatric cardiothoracic surgery program opened.

2. CNN filed a Freedom of Information inquiry to obtain data about the program's caseload, finding 48 pediatric open-heart surgeries were performed at the hospital since late 2011. Since the hospital did not publicly report its mortality rate, investigative reporter Elizabeth Cohen and her colleagues used this information to calculate the death rate for pediatric open-heart surgeries at 12.5 percent, more than three times the national average of 3.3 percent cited by the Society of Thoracic Surgeons.

3. St. Mary's has called CNN's calculations "wrong," "exaggerated," "deeply flawed" and "completely erroneous." As the Columbia Journalism Review noted, St. Mary's said CNN's calculation were based on "an incorrect assumption of volume" since those 48 cases were only open-heart surgeries, even though the STS database includes both open and closed cases, or those performed without a cardiopulmonary bypass machine. The hospital claimed it alerted Ms. Cohen that her figures were flawed in February, and Mr. Carbone said raw mortality data "does not give proper context for the complexity and severity of each case, which would potentially lead to providing misleading information to consumers." 

4. Ms. Cohen said she was aware of this concern and took steps to achieve "an apples to apples comparison" with open-heart surgery mortality rates. She told CJR her team worked with "a highly respected source" who had access to the STS data to retrieve data specific to national pediatric, on-pump surgical mortality rates for 2011-13 for comparison with the open-heart surgery data provided by St. Mary's.  

5. On June 30, St. Mary's released its own data about the pediatric congenital cardiac surgery program, stating the overall risk-adjusted mortality rate was 4.7 percent based on outcomes from January 2011 through December 2014. The hospital acknowledged the program saw less than STS' recommended volume of 100 cases or more each year. It attributed this to the program's infancy and said it was working to build case volume. Lastly, on June 30 the hospital said it would not engage further with CNN and would consider all options "to ensure that the network, its reporters and editorial staff will be held accountable for the inaccurate, misleading and damaging claims."

6. The dispute over mortality rates drew attention from journalistic watchdogs, including those at CJR. Trudy Lieberman, a longtime contributing editor to the publication, led an analysis of the data and spoke to other healthcare experts. "Though CNN should have used more care in how it presented and described the data, given the information that was available, its method for calculating the mortality rate at St. Mary's and comparing it to the [Society of Thoracic Surgeons] national average was basically sound," Ms. Lieberman wrote. "At the same time, the dispute about mortality rates highlights just how hard-to-parse health statistics can be, and how a lack of transparency in the healthcare field creates challenges for reporters and makes these fights harder to resolve."

7. CMS cited CNN's report on June 5 when it launched an investigation into St. Mary's program. At the same time, the Florida Agency for Health Care Administration said the state agency had conducted five visits to the hospital over the past six months and took the CNN report "extremely seriously." The Joint Commission also began an evaluation of patient safety-related events at the hospital in late June.

8. This week, St. Mary's said closure of the program was not based on a decision nor recommendation from the state or a regulatory agency. It said inaccurate media reports made it difficult to "build sustainable volume" for the program, although CNN reported patient volumes that were already declining. Based on documents St. Mary's filed with the Florida Agency for Health Care Administration, there were 27 cases in 2012 and then 18 in 2014.

9. Experts have pointed to that low volume as a sign that St. Mary's surgical team did not have enough cases to build skill or maintain proficiency, particularly since open-heart surgery on babies and children is especially complex. "With 27 cases a year, it would be easy to make a total mess with newborn babies," the former chief of pediatric heart surgery at Cleveland Clinic told CNN.

10. In addition to data, CNN's reporting contains several interviews with parents, detailed accounts of their child's experience at the hospital and the findings of a site visit conducted by other physicians in 2014.

11. One person at the center of the story is Michael Black, MD, MBA, the adult and pediatric congenital cardiothoracic surgeon at St. Mary's. The hospital describes him as a pioneer, one of the Best Doctors in America (named as such six times) and a physician with "passion for mending the littlest or biggest of hearts." The CNN report suggested otherwise.

CNN reported several instances of parents learning their child was not the first to die after surgery performed by Dr. Black. For instance, the initial report states Dr. Black told the mother of 8-month-old Amelia — when first meeting her — he had never lost a patient during his time at St. Mary's. After Amelia suffered complications during the procedure and later developed an infection, she died in the hospital. According to CNN, records showed she was the fourth baby to die there after undergoing heart surgery performed by Dr. Black.

12. In December 2013, after six babies reportedly died after surgery at St. Mary's, CNN reported that Mr. Carbone sent a letter to the state agreeing to an evaluation of the program. Five independent pediatric heart surgeons visited in April 2014, identifying several shortcomings, including a lack of pediatric electrophysiology expertise, inadequate echocardiogram reports, a low volume of cardiac catheterizations and, overall, an "extremely low volume" of cases. When the surgeons visited, no pediatric cardiac patients were in the hospital. CNN obtained these reports through a Freedom of Information request despite St. Mary's objection.

13. The hospital received the surgeons' reviews a month after their visit. It was recommended the hospital halt surgeries on babies under 6 months of age and complex procedures for older babies and children. Shortly after the state shared these recommendations, CNN reported Dr. Black continued to operate on babies under 6 months of age. A hospital spokesperson told CNN the surgeons' reviews were recommendations, not mandates by the state.

14. St. Mary's is owned and operated by for-profit hospital operator Tenet Healthcare, based in Dallas. Joey Bulfin, RN, is now acting as interim CEO of the hospital. She previously served as COO.

Note: This story was updated Aug. 20.

 

 

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