by Jessie Faulkner

St. Joseph Hospital reacted swiftly to a state Department of Health Services report released last month critical of the Heart Institute. The hospital board of trustees "terminated without cause" the heart program's medical director, Dr. Charles A. Dietl, and continued its quest to affiliate with an established cardiac program out of the area, according to a hospital spokeswoman.

The action represents a major overhaul of the program underway before the program restarts sometime early next year.

The Heart Institute operated just three months, May through July, when the hospital voluntarily suspended operations in order to review an unusually high death rate. After a review of the program, state investigators found among other deficiencies that, "Six deaths out of 40 (procedures) represents a 15 percent morality rate. The acceptable national rate is 3-5 percent."

Dr. Dietl, who was the program's only cardiac surgeon as well as its medical director, has at least two more months until his contract expires. Interim Chief Executive Officer Willard Foote said Dietl's continued involvement in the cardiac program hasn't been ruled out.

At the invitation of the hospital as part of its own internal review, the American Society of Thoracic Surgeons toured the facility Nov. 16 and 17; its report is expected by Dec. 10.

In a letter to the community published in local newspapers, Foote announced the hospital's plan to affiliate with an "established cardiac surgery program." The role of the affiliate will be to help the institute restart its cardiac program, provide backup for the cardiac surgeons, participate in the peer review process and consult on surgical procedures.

According to sources, cardiac programs in Redding, Santa Rosa and San Francisco are being considered. The selection of an affiliate could be announced this month or by early January, Foote said.

"Affiliation with a top-notch program will give the Heart Institute added depth and experience, access to established practices and procedures and a team of experts in the field," Foote said. "It is a significant change that we feel will require the appointment of a new surgeon and medical director associated with the program we select."

In addition to the high death rate, the report listed among it findings:

In its plan of corrections included in the report, St. Joseph Hospital offered several solutions and disputed other state conclusions.

The hospital has implemented a written policy covering all surgical procedures performed by the Cardiac Surgery Program, set up extensive pre-operative evaluation on all patients and post-operative reviews as part of the peer-review process. The Cardiac Surgery Committee will meet monthly to evaluate services, and responsibility for ensuring compliance with operation staffing has been delegated to the chief of surgery and the medical director of cardiac surgery. A revised peer review structure is said to be in place to assure adequate quality assurance monitoring.

In the case of the registered nurse working as a first surgical assistant (FSA), the hospital took exception to the state report.

"The hospital wishes to underscore that the RN mentioned in `Finding I' who functioned as a first surgical assistant during open heart surgeries had completed an FSA training program and was at the time in the preceptorship process."

Use of registered nurses as cardiac surgical assistants is common throughout the state, Foote said.

The difference with St. Joseph's program is that the institute had not completed all the necessary paperwork -- both internally and for the state -- to proceed with such an assignment. When a nurse works beyond his or her normal duties, medical approval must follow standardized procedures, the interim CEO said.

Incomplete or absent paperwork was also offered as an explanation of the program's lack of patient-selection criteria for cardiac procedures.

The institute had criteria and medical teams discuss potential patients' cases prior to accepting them -- but it was not finalized and presented in written form, Foote said.

"Clearly there was a sense about the types of cases we should take," he said.

In terms of the Cardiac Surgery Committee, mentioned more than once in the state's findings, the medical staff has more clearly laid out the committee's role in the program particularly in regard to the evaluation of patient care.

Foote declined to comment on a number of the state's findings noting that he was not acting as the health system's chief executive officer at the time. Formerly part of the health system's integrated management team, Foote began as interim CEO following the August resignation of Paul Chodkowski who had accepted a position as CEO of a hospital in his hometown of Schenectady, N.Y.

The selection of the next chief executive officer is nearly complete, Foote said, and may be announced by early December.

One of the new leader's first tasks may be to reestablish the community's trust in the Heart Institute. That process is already underway, according to Foote.

"It is never easy for any organization to go through so many changes, but we have persevered thanks to the hard work and dedication of our staff and your continued community support," he wrote.

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