Hospital accreditation agency investigating complaint about U-M Health System's 6-month delay in reporting child porn
The Joint Commission, which accredits hospitals across the country, confirmed Thursday that it's investigating a complaint that University of Michigan officials waited 6 months before reporting to police that child porn was found on a hospital computer.
University spokesman Rick Fitzgerald said the Joint Commission contacted the U-M Health System and asked for information about the case. He said a response is being prepared.
University of Michigan Hospital
Joint Commission spokesman Bret Coons declined to say who filed a complaint and whether more than one was filed. He said the organization is reviewing the matter before determining the next step.
In May, a resident physician found child porn on a thumb drive that was left in a computer in the Pediatric Emergency Department at University of Michigan Hospital, records show. She suspected the drive belonged to another resident physician and told her supervisors, hospital security and the Office of the General Counsel about it. However, officials didn't report it to police for 6 months.
Stephen Jenson, 36, who worked as a resident physician at the hospital until late December, is charged in the case with four counts of possessing child sexually abusive material.
The Joint Commission is an independent not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs across the country, including the U-M Health System.
Coons said the review includes determining whether the delay in reporting child porn qualifies as a "sentinel event."
In this case, the Joint Commission would have to determine whether the incident put anyone at risk of serious psychological injury and requires immediate investigation. If it qualifies as a sentinel event, the health system would have to do a thorough investigation and prove to the Joint Commission that it's fixed the problem in order to retain accreditation.
"No major determinations have been made yet," Coons said.
The university has acknowledged that the child porn allegation made in May wasn't handled properly and asked the U-M Office of University Audits to review the matter.
Coons said the Joint Commission may respond to the complaint in one or more of the following ways:
- If the complaint raises concerns about a continuing threat to patient safety or if it suggests a failure to comply with Joint Commission standards, we may conduct an unannounced or unscheduled on-site evaluation of the organization.
- We may ask the organization to provide a written response to the complaint.
- If the organization is scheduled for its accreditation or certification survey in the near future, we may review the complaint and the organization’s compliance with related standards at that time.
- We may incorporate the complaint details into our database that we use to monitor quality issues and track trends with our accredited or certified health care organizations.
- Failure to comply with the standards may adversely affect an organization’s accreditation status.
Coons said he didn't know when the Joint Commission will decide how to proceed.
Lee Higgins is a reporter for AnnArbor.com. He can be reached by phone at (734) 623-2527 and email at leehiggins@annarbor.com.
Comments
BhavanaJagat
Sat, Feb 4, 2012 : 7:54 p.m.
The Moral and Ethical Aspects of the Discovery of Evidence: From the story shared here and in the previous reports on this incident, it appears that the female resident who had access to the Emergency Pediatric Lounge used by Pediatric residents has made an illegal discovery of the contents of the thumb drive left behind by another resident(Stephen Jenson). It is immoral, and unethical to open the file contents of a thumb drive by any person other than its owner. The female resident has no legally valid reason to examine the files of a thumb drive to which she has no ownership rights. She did not proceed to open the thumb drive by some mistake. She had very purposefully, and intentionally reviewed the personal file contents with full awareness of the fact that she is not specifically authorized by its owner to use the item. Her discovery of the owner's name and some porn images is invalid because of the illegal search conducted by her. I would expect the Court to reject her evidence and her findings. I am not sure about the discovery made six months later; the circumstances under which a security person reported the matter to the Department of Public Safety. I have to hear that this security person has in fact seen Stephen Jenson using the hospital computer and viewing some child porn image. In the absence of such discovery, there is no legally valid case against Stephen Jenson. If I am the Judge or the Juror, I will not admit this illegal evidence in the trial of Jenson and would not be persuaded to find him guilty of the crime with which he is charged.
pu2um
Sat, Feb 4, 2012 : 4:25 p.m.
@Sparty "The doctor is no longer employed by UM." Only because a lowly security officer defied superiors and took the matter to proper authorities. "The attorney who made the initial determination that there wasn't enough evidence to proceed is no longer employed with UM." Wrong again. There is no chance in hell that Executive Vice President and General Counsel Scarnecchia did not approve dropping this case. She's still providing counsel (and probably has her own attorney by now). You have absolutely no idea under what circumstances the attorney left the employ of UM. Perhaps it was in protest to letting this creep continue seeing patients and bringing his porn to work with him.
sHa
Sat, Feb 4, 2012 : 10:22 p.m.
Finally getting some outside unbiased people looking at this. That is a good thing, right Sparty?
Sparty
Sat, Feb 4, 2012 : 10:10 p.m.
There are multiple investigations underway, along with a Joint Commission review. How is that looking the other way? The armchair detective brigade can relax and let the professionals finish their audits without the hysteria of those without the facts.
Sparty
Sat, Feb 4, 2012 : 7:20 a.m.
Coverup, conspiracy, culture of secrecy .....oooooh. Drama. Can you say paranoia? How about a case of an individual student doctor breaking the law, a viewer of child pornography on home and work computers as disgusting as that is, who works daily with children/minors as scary as that might be. However, there are no claims that the doctor ever had sex or inappropriate contact with a minor. No criminal history at all. And yet ..... Horrible mistakes have been made. The doctor is no longer employed by UM. The attorney who made the initial determination that there wasn't enough evidence to proceed is no longer employed with UM. Multiple audits are underway. Let's see what happens. Now that the Joint Commision is involved, another group can also add their perspective. Perhaps the armchair detective brigade can relax until these groups complete their reports?
sHa
Sat, Feb 4, 2012 : 10:20 p.m.
Finally getting some outside unbiased people looking at this. That is a good thing, right Sparty?
Sparty
Sat, Feb 4, 2012 : 10:09 p.m.
There are multiple investigations underway, along with a Joint Commission review. How is that looking the other way. The armchair brigade can relax and let the professionals finish their audits without the hysteria of those without the facts.
sHa
Sat, Feb 4, 2012 : 1:41 p.m.
@Sparty - Our justified outrage informs the University that the public will NOT "look the other way" and "try to forget" about a UM-Resident-Pediatrician who enjoys child porn, as UM seems to have done in this incident. Would you feel better if we all just yawned and went "oh well"?
trespass
Sat, Feb 4, 2012 : 12:12 p.m.
One of the reasons that we may not know if any inappropriate contact was made was that the U did not notify his patients of his arrest even though the detective testified that the hospital was in the process of doing so. The lawyer has not been named. In fact the U is refusing to name him or her so no one has been able to get their side of the story. That may just be a useful scapegoat for the ones who actually ordered the investigation to stop.
15crown00
Sat, Feb 4, 2012 : 5:06 a.m.
maybe your 14th ranking will recede to an 87th ranking.than what excuse will u find.all this as a result of a COVERUP.
newsboy
Fri, Feb 3, 2012 : 8:36 p.m.
Where I to have seen this type of thing in the Pediatric or Psychiatric depts. of the U Hospitals, I would have thought it to be a research project. I've seen strange things at UofM over the year. On occasion I would ask about the research, other times I was simply too embarrassed, busy or just minding my own professionalism. Like I say; when you've worked at the University you see allot of very weird, legitimate research. For instance; if I were to research some taboo, I would need to have subject matter. Let's just say for instance, the subject matter was; "the decline the democratic state. "So I'm doing my research minding my own, reading Facebook and Comicbook when all of a sudden; Navy Seal Team Six comes through the roof and kills my coworker due to bad Intel! Let's just say I've changed my research to "how to be a more obedient citizen under corporate rule." When asked about my coworker I have "plausible deniability." I can never defend some of the stupidity I've seen come from UofM administration, but there are many caring, hardworking, managers, employees at the University. All I can truly say is; if the hospital where to close tomorrow, the body counts in southeast Michigan would rise by the hour. If you're looking for someone to blame, go to the bathroom and look in mirror. How many times did you question the mistreatment of a child at the mall? How many times have you stopped for a stranger on the side of the road? How many of your neighbors do you really know? It is truly what we all have become, where in lies the problem. Don't blame this great institution for what seems to be occurring in the public daily, right under your self-righteous noses! I hope justice is done in this case, but I have to say "he is no HH Holmes." HH Holmes. Graduated: University of Michigan Medical School, Ann Arbor (1884) Killings 4 to 200.
15crown00
Sat, Feb 4, 2012 : 5:10 a.m.
Tell it like it is and u did.
pu2um
Fri, Feb 3, 2012 : 7:58 p.m.
@pbehjatnia The regents will not fire Coleman. Coleman will not fire Scarnecchia or Pescovitz. And, Pescovitz will not fire anyone either. It's called damage control. They need to keep everyone on board and singing the same tune. Eight months is more than enough to get their stories straight and delete/destroy incriminating evidence. No doubt, they retained outside counsel long before now. So much for for Richard Boothman's ethical standards. <a href="http://www.michigandaily.com/content/medical-disclosures" rel='nofollow'>www.michigandaily.com/content/medical-disclosures</a> Bravo to the hospital security personnel who took the matter to police. Better watch his/her back. UM does not tolerate whistle-blowers kindly.
15crown00
Sat, Feb 4, 2012 : 5:17 a.m.
the whole bunch of them INCLUDING the Regents should be fired.But that would be bad PR wouldn't it? and we can't have that on a campus where everything is thought to be Deep Blue and Colorful Maize all the time. Well things AREN'T always as they appear to be Are They?
Sallyxyz
Fri, Feb 3, 2012 : 5:28 p.m.
Good they are getting investigated, but the UM will wriggle out of this, be assured. They will crank up their PR machine and cover all backs concerned. They will attribute it to a "process" failure, not a failure by the personnel. Medical schools should institute psychological evaluations as part of the admissions process for pediatricians. How many other "pediatricians" with a penchant for child porn are out there practicing or peeping?
ypsicat
Fri, Feb 3, 2012 : 5:55 p.m.
I agree with Sally this time.
Kai Petainen
Fri, Feb 3, 2012 : 4:46 p.m.
Question. Can the university cite constitutional autonomy and just ignore this for 6 months? Im currently in a canadian hospital. This story is horrifying to everyone who hears it.
sHa
Fri, Feb 3, 2012 : 5:21 p.m.
They can, and do, ignore anything they want, until their cover up is revealed, as happened with this incident. Then they are forced to deal with it, whether they want to or not. Thanks to the reporting of AA.com, the University is on the spot. Waiting to see how forthcoming they are going to be...
pu2um
Fri, Feb 3, 2012 : 3:53 p.m.
@Jim Osborn and BhavanaJagat We do not yet know whether patient care has been compromised. Have the parents of Jensen's patients been notified by hospital administration? No, the Joint Commission's investigation will not obscure treatment for heart and cancer patients. But I would argue that the culture of cover-up does have an overall effect on the quality of patient care. Given the secretive nature of the hospital administration, at the direction of the General Counsel, we'll never know.
Jim Osborn
Sat, Feb 4, 2012 : 4:57 a.m.
Great points about the existence of an overall culture of cover-ups at this institution. What if the signs of cancer were missed? If I were to have a need for a heard operation, and the preverbal surgeon's sponge were left in by mistake, would there be a cover-up?
justcurious
Fri, Feb 3, 2012 : 4:45 p.m.
And we will never know what else has been covered up over the years. When the hospital knew the Joint Commission was coming there was tremendous scurrying around to make everything look just right. Then, after the visit it was business as usual and things went back to "normal". "Drop in" visits would be much more effective.
trespass
Fri, Feb 3, 2012 : 4:08 p.m.
The detective testified that the hospital was in the process of notifying patients but it never happened.
sHa
Fri, Feb 3, 2012 : 4:07 p.m.
Yes, the "culture of cover-up" does affect doctor/patient relationships, also those of employee/employee, and employee/employer. It affects everyone. Look at how many people are upset about this incident. This matter needs to be UNCOVERED and full disclosure going forward would be the best way to proceed. No more hiding the facts.
a2citizen
Fri, Feb 3, 2012 : 3:40 p.m.
From the Joint Commissions Sentinel Event Poloicy and Procedures in Behavioral Health: The definition of a reviewable sentinel event takes into account a wide array of occurrences applicable to a wide variety of behavioral health care organizations... The subset of sentinel events that is subject to review by The Joint Commission includes any occurrence that meets any of the following criteria:... 1... 2... 3. Rape <a href="http://www.jointcommission.org/assets/1/6/2011_CAMBHC_SE.pdf" rel='nofollow'>http://www.jointcommission.org/assets/1/6/2011_CAMBHC_SE.pdf</a>
BhavanaJagat
Fri, Feb 3, 2012 : 3:23 p.m.
I am rather surprised to hear about Joint Commission's concern about this incident. There is nothing to suggest that patient care has been compromised and the story is not about a patient's abuse by a doctor. I would like to see as to how the Court deals with this issue. The Joint Commission may provide suggestions to improve the quality of resident training program and recommend preventive measures to uphold the moral and ethical standards of the profession.
mtlaurel
Fri, Feb 3, 2012 : 3:43 p.m.
the visit will be helpful: they have the ability to[ laser-like ]cut to the details of the issue. As well, the problems overall in terms of personnel h/ierarchy/intimidation/fear/reluctant or hesitating behaviours/ inefficienies due to size/politic. can be assessed. It is a huge question why in May, a proactive stance/response was not undertaken... rather baffling coming from the University of Michigan. It is unknown whether patient care was affected-Dr. Jenson continued to practice-there was no escort at his visits with patients. The public deserves to have the comission enter this, altho I think every aspect of this could have been dealt with by the University/law enforcement/social services at the time of the occurrence.
Michigan Man
Fri, Feb 3, 2012 : 3:37 p.m.
BJ - You are incorrect - this matter has serious potential patient safety issues. As a condition of Joint Commission Accreditation, which is voluntary, accredited organizations are REQUIRED to report any and all sentinel events in a timely manner. U of M apparently failed miserably in this regard. One has to ask, I suppose, if this failure was just poorly thought out hospital procedures and lack of monitoring procedural compliance - or a more willful, deliberate and calculated decision not to inform the Joint Commission?
David Cahill
Fri, Feb 3, 2012 : 2:27 p.m.
It's great that an outside group with significant clout is investigating!
sHa
Fri, Feb 3, 2012 : 5:37 p.m.
Let the Board of Regents know how you feel. E-mail each of them at: <a href="http://www.regents.umich.edu/ovp.html" rel='nofollow'>http://www.regents.umich.edu/ovp.html</a>
kms
Fri, Feb 3, 2012 : 3:44 p.m.
It's all well and good that the faculty group is meeting, the Joint Commission is inquiring, the UM Office Of University Audits is investigating...but truly, the group that really matters is the Board of Regents. I'm hoping for a strong comment and action from them. In the Penn State case, it was ultimately the trustees who took action against those responsible for the cover-up.
trespass
Fri, Feb 3, 2012 : 2:52 p.m.
It is a good development but the Joint Commission is a membership organization so they want to assume that their members will fix problems. They will have good intentions but we still have to watch carefully to be sure that the University does not pull the wool over their eyes. That is why we must insist that the University release all documents related to the investigation.
sHa
Fri, Feb 3, 2012 : 2:52 p.m.
Yes, an outside group not interested in hiding anything, should certainly help.
Bill
Fri, Feb 3, 2012 : 2:14 p.m.
The last thing any hospital administrator wants to have happen is to get a call from the Join Commission asking them about an incident at the hospital. Hospitals take the Join Commission investigations and visits very serious. Following a thorough investigation, it may be appropriate to fire some individuals who had knowledge of this incident and did not take any action. This should not stop with a resident or attending, but should go up throughout the organization to the highest levels where the failure to take action occurred. I hope AnnArbor.com will keep a close watch on this story and make sure it doesn't get forgotten after a few weeks.
a2citizen
Fri, Feb 3, 2012 : 1:19 p.m.
"...If it qualifies as a sentinel event,..." Kind of like a major violation. I wonder if the Joint Commission has the same authority as the NCAA. No one will lose their job and we will have to sit out bowl games for two years.
alan
Fri, Feb 3, 2012 : 4:02 p.m.
Two things come to mind trespass. Medicine, particularly diagnostics, is an art, not an exact science. Unfortunately we live in a culture where mistakes are automatically categorized as negligence and the first reaction is that somebody must pay for the mistake. I would venture that the overwhelming majority of physicians do their best but mistakes still happen. They are inherent in the practice. Secondly, the job of the risk manager, after the fact, is to minimize financial loss as a result of the occurrence. They were doing exactly what they are there for. I'm sure that they also enacted controls to minimize they risk of a repeat occurrence but they were doing their jobs.
trespass
Fri, Feb 3, 2012 : 2:48 p.m.
The idea of a sentinel event is the same as a canary in a coal mine. The idea is that a serious adverse event may signal deeper problems that need to be discovered and fixed. That is certainly the case here. This is a horrible event but it is a symptom of a culture of cover up. I was personally involved in another case at UM where a body part was removed because of a missed diagnosis. Risk management was more concerned about whether or not they could be sued than fixing the underlying problem.
Linda Peck
Fri, Feb 3, 2012 : 1:05 p.m.
I believe this is justified. If a pediatrician has a psychological issue with children that involves sadism or other aberrations, and that pediatrician examines and treats children at a clinic, there is a good chance this underlying emotion/thought state will be felt by the children, even if no overt physical abuse is perpetrated. Just the feelings and intention inherent in the doctor's care provided will be felt by the patient, in this case children who are often helpless and vulnerable and often will not speak up when they feel uncomfortable or feel threatened.
say it plain
Fri, Feb 3, 2012 : 10:57 p.m.
Exactly, @Linda Peck, well stated. This guy was still bringing the flashdrive with the porn on it to work when he was caught and had to relinquish it, ick. I have a hard time imagining that his physician's "manner" *at the very least* would have been unaffected by his 'problem' , and it is indeed grossly unseemly that the University has offered in their defense that "no children were harmed by him", that they know of. It's disgusting to think that they would allow anyone they had the slightest suspicion about regarding his viewing of sadistic sexual abuse of children to continue seeing their patients! Their patients! And to allow the resident who reported this to have to live with this "the case isn't being pursued" bottom-line. Educating doctors?! Opening the doors to this brand new *children's hospital*?! Why would they decide to let this slide?! I hope both the BOE and this accreditation agency force them to allow an outside investigation.
average joe
Fri, Feb 3, 2012 : 3:53 p.m.
I always wonder about the statement from U/M that there were no victims of this suspect that they know of. They covered this up for 6 months- how do they know for sure, & what will U/M do if a victim comes forward if there was?
trespass
Fri, Feb 3, 2012 : 12:56 p.m.
It is very unlikely that the Joint Commission would withdraw UM's accreditation but they have a big stick and what they can do is force the University to conduct a proper investigation. If it is deemed a sentinel event, the Universtiy would be required to conduct a "root cause analysis". This is a structured investigation where you work back from the most proximate cause and ask what was the root cause of the problem. I think what everyone commenting wants is to feel that the administration has really found the facts and identified the problems, including the people responsible and takes appropriate action to make sure this cannot happen again. Personally, I think the culture begins at the top.
Jim Osborn
Fri, Feb 3, 2012 : 12:24 p.m.
While a lack of judgment and serious event, this is separate from patient care and should not affect hospital accreditation, other than a requirement that this institution have better policies for handling such events that include calling sworn police officers (not campus security) as soon as discovered and not left to bureaucrats to hide. If my heart were bad or if I had cancer, I would not want this event to obscure the fine care that the UM hospital provides.
Jim Osborn
Fri, Feb 3, 2012 : 8:16 p.m.
Yes, I would not ant this doctor to treat a small child. But he is gone. People with his "inclinations" exist throughout society and UM most likely is not any higher Most likely lower. I am 100% sure that after this incident, UM will be very careful and even safer. Unfortunately, if there is another doctor like him, he now knows what not to do and will not be so stupid.
PhillyCheeseSteak
Fri, Feb 3, 2012 : 7:36 p.m.
Jim Osborn - "If my heart were bad or if I had cancer, I would not want this event to obscure the fine care that the UM hospital provides." OK, but what if your child or grandchild had to be taken to the Pediatric Emergency Room? And the doctor providing medical attention to your child/grandchild was this doctor? Isn't it more than a little bit creepy to think of what could happen to a sick/injured child this situation, being treated by an individual who views child pornography (and brings it to his workplace, which involves taking care of children)?
average joe
Fri, Feb 3, 2012 : 3:47 p.m.
alan- I think that Jim O. was refering to the hospital security folks, not the U/M police. (Think 'mall cop')
alan
Fri, Feb 3, 2012 : 2:19 p.m.
Campus police officers in Michigan are sworn police officers who undergo exactly the same training as all other police officers in the state. Why would you suppose that they are not?
pbehjatnia
Fri, Feb 3, 2012 : 11:58 a.m.
Great. I hope this does affect accreditation. Everyone who knew and chose not to act should be fired. From the resident right on up the food chain. Fire ALL of them.
mkm17
Fri, Feb 3, 2012 : 3:13 p.m.
pbehjatnia said it perfectly: Everyone who knew and chose not to act should be fired. To me, there *are* parallels with the Penn State case here, and it's acceptable to make the comparison.
justcurious
Fri, Feb 3, 2012 : 2:13 p.m.
Basic Bob, I think pbehjatnia was speaking of Dr. Jenson when they said "the resident", not the female Dr. who reported the finding. I could be wrong though, of course.
mtlaurel
Fri, Feb 3, 2012 : 1:19 p.m.
perhaps what will be discovered is whether this was a "communication" lag as the University is saying, or disregard of criminal/potential criminal conduct despite having the pertinent information available. There is a difference...."Firing" can be necessary, however, the "culture" within the organization that could allow willfull negligence vs. "one or two" individuals behaving in an atypical, abhorant manner[violating laws] needs to be discerned.
Basic Bob
Fri, Feb 3, 2012 : 12:17 p.m.
The resident did the right thing and told someone. She knew it was wrong. Too bad no one else cared half as much as she did. Those who knew and chose to do nothing should be jailed, fired, and forfeit their pensions. They are accessories to the crime.
justcurious
Fri, Feb 3, 2012 : 11:36 a.m.
<a href="http://www.jointcommission.org/sentinel_event.aspx" rel='nofollow'>http://www.jointcommission.org/sentinel_event.aspx</a> A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. For more information see Sentinel Event Policy and Procedures. All well and good but who dropped the ball? The resident told someone. Who did they tell. What discipline is in the works?
justcurious
Fri, Feb 3, 2012 : 2:31 p.m.
When I worked at the Medical Center, The Joint Commission was a very feared organization. So, I am assuming that this investigation by them will have everyone jumping. But to me it's simple. Let the people know who failed and why.
Michigan Man
Fri, Feb 3, 2012 : 2:17 p.m.
Yes - This matter meets the definition of a sentinel event! U of M was negligent again in not reporting this sentinel event to the Commission which is located in Oak Brook Terrace, Illinois. The Commission does get a bit pissed off when accredited institutions willfully and deliberately fail to report required events. More trouble for U of M.