Lessons Learned from the Independent Review of Johns Hopkins All Children’s Hospital

Posted on Jun 28, 2019


In December 2018, following a series of Tampa Bay Times articles concerning serious incidents involving the Johns Hopkins All Children’s Hospital Heart Institute, the Board of Trustees of Johns Hopkins Medicine established a Special Committee to review potential deficiencies that may have contributed to these incidents and to develop recommendations to address and correct any deficiencies. The Special Committee retained Gibson, Dunn & Crutcher LLP to undertake an external review to identify deficiencies at JHACH and JHHS and to make recommendations in connection with its observations to assist the Special Committee in carrying out its mandate.

Read the Recommendations

Video Transcript

Earlier this year, I shared with you that the board of Johns Hopkins Medicine commissioned a comprehensive external review of the failures in care at the Johns Hopkins All Children’s Hospital Heart Institute.

Today, I’d like to provide an update on the review.

Over the last 6 months, a team from the law firm Gibson Dunn conducted a thorough, top-to-bottom analysis of the events and systems that contributed to the failures of care. Their review was comprehensive, rigorous and unsparing.

They examined meeting minutes, event reports, personnel files and employee engagement and safety surveys.

They ran targeted searches of nearly 7 million documents and closely reviewed more than 140,000 based on those searches.

They conducted more than 120 interviews with current and former employees of Johns Hopkins All Children’s Hospital, Johns Hopkins Hospital, the Johns Hopkins Health System, members of the All Children’s Board and the Johns Hopkins Medicine Board as well as others.

The hallmark of an institution’s safety culture is how it responds to and corrects errors when they are made. At Johns Hopkins, we are committed to doing everything we can to ensure that what happened never occurs again at any of our hospitals or at other hospitals around the country. That’s why, when we announced the creation of this independent review, we also committed to sharing the lessons learned.

Today, we have posted the recommendations of the external review online and we encourage you all to review it. The recommendations focus on four key areas.

First, strengthening the management and culture at Johns Hopkins All Children’s Hospital. This has a particular focus on improving channels for staff to report concerns while also bolstering leadership training and tackling system-wide integration challenges.

Second, improving our processes for evaluating patient clinical quality and safety.

Third, clarifying and streamlining the reporting structure between the six Johns Hopkins Hospitals and the Johns Hopkins Health System in order to integrate and standardize oversight.

And, finally, reviewing the ways in which the boards of Johns Hopkins All Children’s Hospital and Johns Hopkins Medicine should advance their governance responsibilities.

The boards of both Johns Hopkins Medicine and Johns Hopkins All Children’s Hospital approved the findings and have directed leadership to implement the recommendations presented in the review. We have already begun implementing changes that address some of these recommendations. In the coming weeks, the board of Johns Hopkins Medicine will appoint a monitor to track and report regularly back to them on the hospital’s progress.

While the initial focus of the implementation process will be on All Children’s hospital, a team will come to each of the other five Johns Hopkins hospitals to evaluate them against the recommendations. This will ensure that the entire Johns Hopkins Health System receives the full benefit of the review and will make us stronger and better-integrated across our hospitals.

You will hear more from your leadership about how the next steps will impact you and your work. These steps are each geared toward a single purpose: to continuously improve the world-class care that is our promise to all our patients.

Above all, we must work every day to support a culture in which each of us is empowered and encouraged to speak up and speak out. If you have a concern about patient safety, misconduct, illegal or unethical behavior or anything else, please call the Johns Hopkins Medicine hotline at 1-844-SPEAK2US. The line is operated by an external vendor and is open 24-7. If you choose, you may remain anonymous.

As always, thank you for all your hard work. Johns Hopkins Medicine remains committed to the Tampa Bay community and proud of all who care for our patients with excellence every day.

Thank you.

Statement from Sandy Diamond, Chair of the Board, Johns Hopkins All Children’s Hospital

The board of Johns Hopkins All Children’s Hospital has directed leadership to implement the recommendations of the independent review team from the law firm Gibson Dunn.

This was an extraordinarily rigorous process. The review team conducted more than 120 interviews with current and former employees and had unfettered access to staff, personnel files, and meeting minutes. They ran targeted searches on almost seven million documents and closely reviewed over 140,000 of them. We are confident that throughout the process, no stone was left unturned.

This has been a difficult time for our hospital and our community. Last winter, we promised to get to the bottom of what went wrong at the Heart Institute so that we could ensure that the failures that took place there never happen again. The report released today is an essential part of that process and provides an important roadmap for us as we work to constantly improve the care we give to our patients and rebuild trust with our community. As an international leader in pediatric health, we hope that the lessons learned in this report will also help other hospitals around the country and the world improve the care they provide to their patients. 

Our commitment to serving our community and our patients with compassion and distinction has never been stronger, and we look forward to working with the monitor to ensure that the recommendations in the report are implemented across our hospital.

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