Feb. 10, 2012
The University of Michigan today released an internal review of the circumstances surrounding a six-month delay in appropriately responding to allegations of possession of child pornography by a medical resident.
What happened?
Details, including a chronology, can be found in the report by the University Audits office.
Who reported this in May? To whom – and who investigated it?
Details are available in Section III, Management’s Response to Report, of the University Audits report.
How did this get reported again in November? Who reported it?
Details can be found in the report by University Audits.
Who is at fault for the delay in properly reporting?
This was a serious failure on the part of the institution — not only the delay in properly reporting the accusation to DPS, but also in failing to recognize and act on a potential patient safety risk even in the absence of a criminal investigation.
Findings indicate that an attorney in the Health System Legal Office acted improperly when the incident was reported to her. But, as outlined in the Management Response, there were missed opportunities to appropriately report by others in the institution who were aware of the allegations in May. Details can be found in the Management Response. Details of the breakdowns can be found in the report by University Audits.
Did any of the child pornography contain images of patients?
We have no evidence that any of the pictures contained images of our patients and we have no evidence that the accused personally took any of the pictures.
Some of the images match those in national databases for law enforcement investigations, according to DPS.
Has anyone been fired or disciplined for mishandling this situation?
The person most involved in this situation is no longer employed by the University. Her departure was not connected to this specific matter.
According to the Management Response:
Individual corrective action will be taken with the involved current employees to ensure greater clarity of their respective roles and the importance of vigilance when handling complaints of possible criminal activity or risk to patient safety. This corrective action will be documented in the employees’ personnel files and those employees will be held accountable for improvement through the established performance review process.
How does the university respond to accusations of a cover up?
University Audits did not find an indication that anyone they spoke with intentionally delayed investigation of the allegations. However, it is clear that there were missed opportunities to appropriately report on the part of employees who were aware of the allegations in May.
Did the University reopen this case after the Penn State revelations?
Yes. One of the reasons the original-reporting physician looked into the status of the case was the heightened awareness of child protection issues following the Penn State incident. The other reason was that the physician learned that the attorney who had initially investigated the allegations had left the University.
In November, the matter was raised for the first time with the Office of Clinical Affairs, the department charged with ensuring every physician’s competence to deliver safe patient care. The case was investigated by DPS and sufficient evidence was discovered that led to the arrest and termination of a suspect in the case.
Why would the Legal Office get involved in such an investigation?
The Health System Legal Office handles a wide range of legal issues and would be involved in investigations from that perspective.
The office does not, however, have the authority to lead criminal investigations. The attorney in the Health System Legal Office inaccurately viewed herself as the appropriate person to lead an investigation. Because of her expertise and experience as a former prosecutor, she assumed responsibility for the investigation. Her colleagues assumed that she was working with Health System Security and did not understand that others viewed her as managing the criminal investigation, an inappropriate role for a University attorney.
Why does the hospital have its own security force? Why are they not a part of DPS?
Most hospitals in America have security forces, and in fact there is a special certification for health care security because of the special issues involved in the hospital environment.
Security and policing are two different professions, and security staff members are trained to call police to handle criminal matters.
Hospital security staff at the Health System handle a wide range of duties, including helping health care staff manage patients and visitors who are enduring highly stressful and emotional life events, and preventing and deterring crime across a large physical environment.
Why did the University choose internal auditors?
President Coleman asked University Audits to conduct an initial review because it could be accomplished quickly and effectively. The Audits office sends reports directly to President Coleman and the Board of Regents, and the office is a group of highly respected professionals whose sole responsibility is to examine, evaluate and recommend improvements to the University’s internal process and procedures. They were in the best position to immediately begin the review and develop recommendations.
President Coleman mentioned in December that the University was creating a task force to deal with abuse and other issues, is that force being used here?
No, that’s a separate issue. That task force was charged with taking a broad look at all of the University programs that include children to review the safeguards that are in place. The task force is beginning its work.
Is the University considering asking anyone outside the institution to conduct a review as well?
Yes, President Coleman has said she will move forward on the audit recommendation to bring in outside expertise to assess communication and cultural issues within Hospital Security, the Department of Public Safety and several other units with whom they interact. Additional steps may be necessary in the future.
When did President Coleman ask for the internal review?
Dec. 3 is when President Coleman asked University Audits to conduct the internal review, one day after learning of the six-month delay in responding promptly to the report of allegations.
For more details on the chronology, see the report by University Audits.
What is the reporting relationship of DPS and Hospital Security?
DPS and Hospital Security are collaborative partners. There is no direct reporting relationship between the two separate departments. Management of each department has agreed that all crimes about which Hospital Security is notified will be reported to DPS.
Tim Slottow, executive vice president and chief financial officer, has management responsibility for the Department of Public Safety. Ora Pescovitz, executive vice president for Medical Affairs, has management responsibility for Hospital Security.
Was Housing Security involved in this situation?
No. Housing Security was not involved in this incident in any way.
Management believes, however, that it is important that Housing Security participate in the comprehensive efforts to ensure the development and implementation of a shared security vision campus-wide.
What are the governing structures of the Health System, the Medical School and main campus?
The Health System, which includes the Hospitals and Health Centers, the Medical School, the Michigan Health Corporation and shared administrative services, reports to the Executive Vice President for Medical Affairs who reports to the President.
The Dean of the Medical School reports both to the EVPMA and the Provost.
All physicians who see patients at U-M Hospitals and Health Centers facilities are faculty of the Medical School and members of its Faculty Group Practice.
All residents, who are also called house officers, are both employees of the Hospitals and Health Centers, and trainees in graduate medical education programs offered by the Medical School.
Who does a resident report to?
Residents have several different supervisors, including the attending physicians they work with and the faculty who run their training program.
Does the Health System do background checks?
Yes, all health care providers receive background checks before hire, and periodically throughout their employment.
What safeguards are in place to prevent doctors, nurses and others from viewing pornography on Health System computers?
Some computers in the clinical environment, and the entire Health System Guest Wifi network, have built-in filters to block access to pornography sites and other types of sites.
All other computer use at the Health System is subject to the same standards as the rest of the University.
U-M specifically bans the viewing of child pornography on any U-M computer system through its Standard Practice Guide, but does not typically block access to Web sites.
What restrictions are there on how U-M employees can use U-M computers for personal uses of any kind?
The U-M Standard Practice Guide, 601.16, generally says that use must be minimal, must not interfere with work duties and must not be related to personal political activity, outside business interests or child pornography and other illegal materials.
Is anonymous reporting of complaints or problems allowed at UMHS/U-M?
Yes, the Compliance Hotline is promoted as offering both anonymous and confidential reporting. The hotline is highlighted at orientation and promoted to staff and faculty throughout the year. An outside vendor is used to encourage use of the system, and to allow for 24/7 access and true anonymity and confidentiality. The hotline has been part of the University’s fabric since 1996.
Faculty, staff and students also are told they should start by raising concerns through management but if that attempt fails, they are uncomfortable about using this channel or the concern is about their chain of reporting that they should use the hotline.
Is the Department of Education reviewing this incident?
The Department of Education, which conducts program reviews of Clery Act compliance, has requested information regarding this incident.
Is this crime one that would need to be reported in the annual statistics for compliance with the Clery Act?
The Clery Act requires higher education institutions to report certain crime statistics and security-related policies annually, among other elements. Clery-reportable crimes include, for example, such classifications as aggravated assaults, sexual assaults, robberies and bias-motivated crimes.
Is the Joint Commission on Hospital Accreditation investigating the incident?
The Joint Commission has requested information from the Health System in order to conduct a review of this incident. The Health System is responding swiftly to their request.
Dr. Pescovitz has said the Joint Commission, as a trusted outside agency with great expertise, is “in an excellent position to review the systems and procedures we have in place that are designed to protect our patients. Patient safety is our utmost priority as a health care provider, and as we strive to further improve, The Joint Commission may be in a position to offer further guidance.”
