October 15th, 2014

woods, Elizabeth, camera, April

Ebola: When the Lightbulb Doesn't Want to Change

Texas Health Presbyterian Hospital--the hospital that misdiagnosed Mr. Duncan in the Emergency Room and sent him home, and then--once he came back with Ebola diagnosed by a family member--not only did not save his life, but managed to allow two nurses to become infected with Ebola while treating him--is a member of a group of hospitals run by Texas Health Resources.

"I don't think we have a systematic institutional problem," Dr. Daniel Varga, chief clinical officer of Texas Health Resources, told reporters, facing questions about the hospital's actions.

Medical staff "may have done some things differently with the benefit of what we know today," he said, adding, "no one wants to get this right more than our hospital."

Dr. Varga is wrong.  He is wrong factually (just the ER visit alone shows that THPH has an institutional problem in its Emergency Department--which other previous complaints and ratings also showed, previous to Mr. Duncan's visit.)   He is wrong in implying that medical staff acted properly with the knowledge they had at the time: they did not.  He is wrong administratively and politically, in not facing the reality and accepting responsibility.    Yes, there is an institutional problem.  His name is Dr. Varga.   He is the reason--or one of them--that Texas Health Resources has an institutional problem, and every other hospital in that group probably has the SAME institutional problems as THPH.

Dr. Varga just screwed the pooch.

So when the lightbulb doesn't want to change, and the lightbulb should be giving the light needed to see and fix a problem...you reach up and yank that sucker out of there and put in a new one.  A different one.  Both the CEO (to whom Dr. Varga presumably reports, and whom, presumably, he's shielding here) need to be replaced, and the replacements need to be informed upfront that they will be held accountable for lapses in quality care.

And in the meantime, the relevant hospital accreditation board should take a long hard look at not just THPH, but every other hospital within the Texas Health Resources group.  At the least, these hospitals should be audited for quality in every kind of case they accept, and put on probation to ensure they meet all standards in all areas.  I wouldn't close them all...but patients deserve better--all their patients deserve better.