The statement was posted on social media.
"Last week, there were post-cardiovascular surgical deaths," White said in the statement. "What concerned the team was that it is atypical for us to see a cluster so close together. This does NOT mean anything was wrong with the care. But, as any high quality organization would do, the team, including the physicians and staff, felt it was important to elevate this issue voluntarily. We did so. Ballad Health deployed its quality support team, infection prevention team, and corporate resources to assist Holston Valley in reviewing the situation."
Tuesday morning of last week, White said, Ballad Health notified the Tennessee Department of Health and Centers for Disease Control to inform them of the review. The Tennessee Department of Health, and the local Health Department, at Ballad Health's request, deployed a team, including epidemiology, pharmacy and other support, to work with Ballad’s physicians and staff to conduct an in-depth review.
"Again, there was no indication anything was done wrong, other than the timing of these outcomes being so close together," White said. "The technical, scientific and clinical expertise of the Department of Health and the CDC was incredibly helpful to our internal teams, and also served to validate our process."
Conclusion of findings
White said after several days of intensive and clinical review, laboratory testing, staffing reviews and evaluation of the environment of care, Ballad Health, along with state and federal experts, reached the unanimous conclusion that none of small number of recent patient outcomes occurring in Holston Valley’s cardiac program were the result of any infection or any systemic issue.
"In fact, all investigators agreed that these outcomes were not in any way clinically related and could find no causal factors that would lead anyone to believe the standard of care was not followed," she said. "Patient records were reviewed extensively, and over several days, every aspect of care was reviewed. The ultimate conclusion is that the outcomes were not outside the scope of what would be expected based on the severity of the patients' illnesses."
Breach of trust
White disclosed the process was undermined by a person, or people, who chose to violate the sacred trust of this process by sharing confidential, invalidated and inaccurate information with people outside the organization.
"Doing so only served to frighten people and harm the integrity of this institution," she said. "How can people depend on this process to work if it is undermined by a person, or people, who would take it upon themselves to communicate inaccurate, invalidated and false information publicly? I can think of little that does more to undermine the good faith efforts of our exceptional physicians and clinical staff who have worked so hard to create such a high quality and internationally acclaimed heart program. Had there been a systemic issue, we would have taken the appropriate action to communicate that to the families of the patients affected, to our team members, physicians, the public and to our regulators. In this case, our regulators were already in the hospital conducting the review by our side, at our request.
"Instead, there is an individual, or individuals, who chose to take matters into their own hands, and they shared information outside the organization that was not accurate, and potentially damaging — not only to our hospital, but to the families who may have lost loved ones to a terrible disease whom the evidence shows we did our best to help. This action undermined the professionalism and expertise of our clinical staff who have worked so hard to build a high quality program, and flies in the face of every evidence-based best practice designed to deliver the highest quality of care. This information was then irresponsibly shared on social media and false information was spread through that venue.”
"I want to be clear about this: This is not tolerable, and steps will be taken to identify who violated our policies, and maybe even the law. We will seek to hold anyone accountable who spreads misinformation about patient care, and we will do so unapologetically. I have spoken with the leadership of Ballad Health, and they are in full agreement with my concern, and any actions necessary to bring this to a conclusion. If you are the person or persons who violated the trust of this process, the respectable thing to do would be to step forward, and take responsibility for your action. I would encourage you to do this."