'Serious breach' of policy

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Barb Sweet
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Internal probe reveals biochem lab errors not documented, revealed to Eastern Health executive in timely manner

Occurrence reports on problems in Eastern Health's biochemistry lab should have been submitted as early as last fall, but no documentation was filed until Eastern Health CEO Vickie Kaminski asked for it Feb. 19.

Nor was Kaminski and the executive informed in a timely manner of the cyclosporine testing errors. There was some hint of a problem in the lab last fall which wasn't reported. At the time, however, the lab wasn't aware patients were getting incorrect results. In January, a nurse redflagged testing discrepancies, but it was a month later Kaminski was told of the errors and no report was done until she asked for it.

Eastern Health president and chief executive officer Vickie Kaminski, answers questions during a Tuesday afternoon news conference. - Photo by Joe Gibbons/The Telegram

Occurrence reports on problems in Eastern Health's biochemistry lab should have been submitted as early as last fall, but no documentation was filed until Eastern Health CEO Vickie Kaminski asked for it Feb. 19.

Nor was Kaminski and the executive informed in a timely manner of the cyclosporine testing errors. There was some hint of a problem in the lab last fall which wasn't reported. At the time, however, the lab wasn't aware patients were getting incorrect results. In January, a nurse redflagged testing discrepancies, but it was a month later Kaminski was told of the errors and no report was done until she asked for it.

The revelations came as Eastern Health released the findings of an internal investigation of the cyclosporine testing errors Tuesday.

"The policies for occurrence reporting and reporting through the channels were not followed," Kaminski told reporters Tuesday, adding all those polices were widely distributed to staff.

"It is a serious breach of hospital policy."

All that flies directly in the face of the evidence and findings of the Cameron Inquiry into immunohistochemistry lab testing errors to determine breast cancer treatment, a scandal that rocked Eastern Health and the Department of Health.

The labour of that inquiry was compounded by the lack of reports on what had happened in the immunohistochemistry lab over several years.

A year after Justice Margaret Cameron filed her report on the breast cancer scandal, Kaminski - hired last June to clean up the authority's act - was in the embarrassing position of having to say Tuesday the biochemistry errors were not properly documented.

About the same time the media received the internal report Tuesday, it was given to the board of directors and Health Minister Jerome Kennedy.

Kaminski hadn't had time to hear reaction from either Kennedy or the board, but she didn't expect the province to be pleased with the latest boondoggle.

"I would assume that they are not any happier about it than I am," Kaminski said Tuesday.

"I can only expect (Kennedy and Premier Danny Williams) will want to see the policies and procedures followed and they will be expecting the education program we will put in place (to work)."

Minister expected to comment today

Kennedy is expected to comment today. Kaminski was also meeting with lab personnel today. In its internal findings, the authority said there will be an education push regarding the need to document and file occurrence reports in the lab. But Kaminski has not ruled out disciplinary action.

She said the errors were being talked about within the lab, but not documented.

"It was a matter of everyone waiting for someone else to do it," she said. "I'd rather have too many occurrence reports than not have a report filed."

"They did actually talk right up to the manager level. But at the manager level, what happens from there gets a little bit watered down and it didn't come through to the executive team in a timely fashion."

Machine incorrectly calibrated

On Feb. 23, the health authority publicly revealed a lab machine called the mass spectrometer analyzer was incorrectly calibrated -providing test results that led to patients receiving too much of the drug cyclosporine.

It's given to patients with immune system disorders or as an anti-rejection drug for organ transplants. Too much can be toxic.

The errors could affect as many as 212 patients, fewer than originally thought. But one teenager remains in the Janeway intensive care unit in critical condition. He was already ill when he was given too much cyclosporine.

The health authority installed the machine in June 2009.

A renal transplant nurse flagged problems with patients' results sometime during the week of Feb. 8, reporters were told when the errors were revealed at a Feb. 23 news conference.

But Tuesday, the release of the internal report revealed the errors were actually flagged to the lab on Jan. 18, weeks earlier than first indicated.

Media were told at the initial news conference problems showed up last October, November and December with some "unexpectedly low" results for the drug cyclosporine, but they didn't cause doctors to point fingers at the lab testing as they frequently reorder the tests.

However, Kaminski acknowledged occurrence reports should have been filed last fall - months before the errors were revealed to her. It's not known if the problem would have been caught had those reports had been filed in the fall, but reports should have been done. Even when the nurse spoke up in January, there was still no report.

When Kaminski asked for the occurrence reports Feb. 19 after she was informed of the errors, lab officials completed them. The report was done over that weekend and handed to her the following Monday.

Cyclosporine testing in the province was suspended Feb. 12 and is now being done in Halifax.

The machine was not calibrated to recognize there can be an interfering substance, known as metabolite, which exists naturally in the metabolism of some patients and in rare instances can interfere with cyclosporine causing the machine to show artificially low levels of the drug in a patient's blood.

Manufacturer directed installation

That problem was identified in a 2005 research paper. Eastern Health did no literature research when it acquired the machine. The manufacturer, Waters Corp., was brought in to direct its installation. That paper identifying the metabolite problem was not identified in the manufacturer's standard operating procedures, which are relied on when machinery is set up.

Kaminski said the manufacturer was asked for an explanation and at first indicated it would give a "measured response." Then it said it wouldn't be responding.

Eastern Health's lawyers are now examining the manufacturer's responsibilities. Kaminski said although the paper may not have turned up in a literature search, Eastern Health is taking responsibility for not doing the search.

Labs across the country have also been advised of the errors, and Kaminski said they are checking to see if they were aware of the metabolite problem.

Thursday, University Health Network of Toronto will begin its review of the biochem lab and that is expected to be done quickly. Then the outside investigators will review all Eastern Health labs and that will take a couple of months. But Kaminski said the authority will get those results in early June. Once reviewed, the final findings will be revealed publicly.

Meanwhile, eight of the 212 patients affected have died. Five of those have been ruled out as having anything to do with the errors and three remain uncertain. Of all the patients, 75 were told their test results were in error, but their health is not at risk. Not all retests have been done.

The clinical epidemiology unit at Memorial University has been contracted to do a review of the effects the errors have had on the patients, who were all to be notified of the errors by letter and through physicians. For those who have died, Eastern Health is trying to find next of kin.

bsweet@thetelegram.com

Organizations: Department of Health, Waters Corp.

Geographic location: Halifax, Toronto

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Recent comments

  • patricia
    July 02, 2010 - 13:35

    get rid of all those who can not do their jobs properly.There is too much carelessness going on and it affects those patients who are most vulnerable--the transplant patients who rely on proper analysis of their bloodwork to judge the right amount of cyclosporin the should be taking to preserve their transplanted organ.I know, because my daughter is one of them.We put our trust in the system.It can mean the difference in life and death for these patients.

  • William
    July 02, 2010 - 13:34

    its not very i agree with nasty nate, there should be only one thing happening here, instead of pointing fingers the head of this department should be shown the door for trying to cover something like up especially after the cameron inquiry, ms vickie you have internal problems

  • Member of the 93%
    July 02, 2010 - 13:31

    I worry what machine, procedure, or test will provide the next debacle. Are there people getting blood work done today, who will find out a few months from now that some dolt screwed up the process, or didn't know how to use a machine, or whatever? Ms. K. was brought here at great expense, nearly half a million a year in salary and extras, to fix a broken system. In my humble estimation she has failed. I'm sure we could have found a newfoundlander who could have failed just as well, probably for a few hundred K less.

  • AR
    July 02, 2010 - 13:31

    Its utter nonsense to point fingers at Vickie Kaminsky. She's the president and CEO of Eastern Health; she wasn't hired to micro manage and it's absurd to expect her to be aware of errors that have not been reported to her. The person(s) who did not comply with the policy regarding the submission of occurrence reports should be suspended or fired.

  • Robert
    July 02, 2010 - 13:29

    BOTTOM LINE: Ms. Kaminski was brought in at a very large expense to make sure these problems never, ever happen again because peoples' lives hang in the balance. Well, guess what, they are happening again.

  • Taxpayer
    July 02, 2010 - 13:28

    Robert if you are in the private sector then you don't know anything more about the operation of Eastern Health than anyone else on the site. So what is going on. Do you imagine that you are some kind of expert. More likely just another time waster.

  • Nasty
    July 02, 2010 - 13:27

    Stop pointing fingers Vicki. You were hired to fix the problems yet you have done very little. Your quarterly performance review shows you have failed to revamp policy and procedure. You have failed to be proactive in correcting known issues. You failed to implement the recommendations of the Cameron Report. You have failed to re-write internal work practice, policy or procedures.

    Must be nice to receive a six figure salary to do nothing more then pass the buck. Explain again just why you should remain in this position.

  • Taxpayer
    July 02, 2010 - 13:26

    Yes your right Robert. Responsibilty always starts at the bottom. What did the CEO do to ensure that all staff were aware of the procedures and that the knew they were to be followed strictly. Yes Money for nothing and your trips for free.

  • Robert
    July 02, 2010 - 13:25

    Taxpayer - I work in the private sector and what I do with my time is none of your business. I am accountable for my performance, and when that performance is below expectations, I will answer for it. This year I got a raise and a sizable bonus based on performance - how about you?

  • Andrea - Lab Tech.
    July 02, 2010 - 13:24

    gut it from nl writes: The next time I see Lab workers on the pickett line, I won't be honking my horn in support.

    If you had any clue as to what's really going in there you'd realize that 'Now' is the time the Lab workers need your support.

    We've been saying for years that there have been major problems in the labs of Eastern Health for years and no one listened. Government and Management has had us on ignore and the moment we try to pass our concerns on to the public the news media and people like you always say Oh, there goes NAPE again looking for money.

    There in lies 'your' problem; not ours. We tried to do our jobs the way we were trained and whenever we tried to voice our concerns, we were told to shut up. Dont expect us to take the blame for this frustrating and deadly mess because thats not going to happen.

  • Billy
    July 02, 2010 - 13:24

    Being totally lacking in management skills, I have absolutely nothing constructive to add to this discussion.

  • Hilda
    July 02, 2010 - 13:24

    You pay small bucks for an average manager to just fire people. You pay big bucks for a great manager to get in there and solve problems pro-actively (pro-active management = micro-management). What problems has V. Kaminski solved?

  • Lee
    July 02, 2010 - 13:23

    Same ole; same ole.
    I'm sick to death of all this blame game, neglect, pass the buck, whatever, but the bottom line is that people's very lives are
    resulting in DEATH.

  • HSE
    July 02, 2010 - 13:22

    I need to jump into the fray here since there have been points made which hold relevance.

    When I take over the management system of any new venture, I make it my personal responsibility to review all relevant documentation to ensure they meet or exceed the requirements set forth in my mandate or under legislation. Due diligence is key. If Vicki Kaminski had done this she would have been able to identify any and all deficiencies as they may have related to reporting or procedures. This by her own words was not completed.

    How is it then not the fault of the CEO in this case? To attempt to place blame on others shows great flaw in character and installs a lack of confidence in the system as a whole.

    When managers or CEOS fail to actively participate in all areas of operation we see a complete breakdown of the system. This micro-management practice shown by far too many is a systematic cancer which needs to be weeded out before it spreads any further. If Vicki Kaminski can not be more hands on, she requires her team to follow up daily with action items to ensure quality and safety or step aside so that she can be replaced with a more competent individual.

  • Mary
    July 02, 2010 - 13:22

    To Nasty Nate: If management has policy, procedures and have staff taught about what has to be done, then management has done this part of its position. There was to be a written report from the get-go. If management finds out about a month after the first verbal report, then let them discipline and keep the public informed. Nasty Nate, you must want management to micro-manage the whole of Eastern health. Too bad Nasty Nate but you are just too mean spirited and ignorant as to what management is all about.

  • Robert
    July 02, 2010 - 13:21

    Andrea - out of curiousity - is your CEO telling you to shut up or a lower level manager?

  • gut it
    July 02, 2010 - 13:20

    What a mess!

    As far as I am concerned, Eastern Health needs to be reviewd from top to bottom. Screw ups due to poor training or bad work ethic up need to be delt with by re-traing or terminations, and this means front line workers and management.

    The next time I see Lab workers on the pickett line, I won't be honking my horn in support.

  • Ed
    July 02, 2010 - 13:19

    Note to Lab Worker - Andrea....
    Who is telling you to shut up? Go around them - write a note /email to the CEO, report the problem to the newspapers, NTV, CBC.
    We are talking about peoples lives not a bad paint job on the ceiling of you kitchen or a poor repair on dent in your car door.
    Just keep in mind that those tests you are doing are for someone's mother, husband, wife or child - treat them like they were yours.

  • Gerard
    July 02, 2010 - 13:17

    Nasty Nate is right on this one and Robert has no clue. Kaminski is fully accountable to set policy AND to ensure policy is followed. If she cannot get full compliance from her staff, a job she was primarily hired to do, she has failed in her job, and as a result has proven to be an ineffective manager - a mouthpiece. The buck stops at Kaminski for her inability to effectively maintain a competent staff who follow policy. Ms. Kaminski, I would suggest you implement a policy which strongly encourages error reporting, such that your employees know in no uncertain terms the negative results of non-compliance. This is clearly where you failed.

  • Bear
    July 02, 2010 - 13:17

    When is somebody going to take the bull by the horns and fix the problems in the health system. Seems like one big mess after another. If it's incompetence, fire the whole works and start from scratch again.

  • Saucy Face
    July 02, 2010 - 13:17

    Vicki while stounding tough and thorough is only coming accross as a plant to protect the healh mininster by trying to give the finger to the ordinary lab worker following orders and deflecting blame from management where it belongs. The buck stops here is obviously not a sign you'll find on her desk.

  • Robert
    July 02, 2010 - 13:15

    HSE Manager - you contradict yourself. You expect Kaminski to ''review all relevant documentation to ensure they meet or exceed the requirements set forth in my mandate or under legislation.'', and in your next breath, you complain about micro-management causing harm to the system. You can't have it both ways.
    Kaminski has managers reporting to her that are responsible for ensuring all policies and procedures are followed. If they are not being followed, it is their duty to inform her so that she can enact remedy.
    HSE manager, if you are in fact a manager and your attitude is ''I'm not responsible to do my job until the boss finds out that I'm not doing it correctly you clearly do not understand your role and do not deserve your position. You are correct - blaming others for failing to do your job is a sign of poor character. In this case, Kaminski did hers, and you are attempting to blame her because a lower level manager did not do theirs. Hypocrite.
    Vicki - I'd agree with you if the policies were not in place but the fact is that they are; they are not being followed. No human would be able to review each policy at the department level personally and ensure that each staff member is doing their job while delivering on the other duties that a CEO has. That responsibility must be delegated out to less senior managers. Management is a team effort, and if team members are not doing the job that that they have been instructed to do, they should be disciplined. People in NL love hockey. We all know that you don't fire the GM because the team is playing poorly. You fire the coach and replace them with a better one.
    If the GM is unable to do so - that's when their head goes on the block.

  • Vicki
    July 02, 2010 - 13:14

    Robert from NL says, you cannot manage without accurate information. Thats right Robert, and Kaminski is ultimately responsible for getting accurate information through her policies, procedures and disciplinary tactics. She failed.

    Maggie from NL, Kaminski did know what she was in for ? $400,000 in salary and benefits. What completely inept person would say no to that ? Work for a year, be found unfit for the position and get fired. Wheres the risk in that ? (Like most company CEOs.)

    Kaminski is totally responsible for this mess. It is Kaminskis responsibility to lead the pack. She sets the policy and she sets the discipline. If just one of these policies is not effective, the whole system breaks down. There is no way she can distance herself from this mess since this is exactly what she was hired to do. Kaminski should have kept a close eye on these things, and if you want to call it micro managing then fine, she needed to do whatever it took to ensure this would never happen again. A good manager, a good CEO, knows all aspects of his company and keeps his ear to the ground, not in the clouds. She is paid handsomely enough to follow every step of Eastern Health. If her job was only to fire managers below her whom she blames, we could have saved a lot of money and hired a McDonald's manager. But no, we hired her, someone supposedly who could super manage this institution, and paid her well to do just that. Standing back and blaming others is not good management. For the simpler folk among us who do not understand this concept, and know nothing about management, refer to your favourite television show Dragons Den and see how real pros do, in fact, what you call, micro manage. This term is a cop-out for lazy management types who simply like to shift the blame. Kaminski should have had her focus on what she was hired to do. She dropped the ball.

  • Robert
    July 02, 2010 - 13:14

    HSE Manager - the only thing unfortunate is that you are long on rhetoric and bureauractise but short on fact. You don't need to 'read between the lines' - just read the story and stop making things up.
    ''The policies for occurrence reporting and reporting through the channels were not followed,'' Kaminski told reporters Tuesday, adding all those polices were widely distributed to staff.''It is a serious breach of hospital policy.''
    Managers were not doing their jobs.
    This issue (as reported) is not related to a system failure - Eastern Health's managers did not follow policy.
    The real cancer that affects our public service is lack of personal accountablity. Some employees get it, but too many more think 'that's not my job' and do nothing. In this case, the lab workers did their jobs and advised their managers. The managers dropped the ball and appear to be incompetent.
    Some free advice - you need to look up the term 'micro-management' - your use of the term does not support your case.

  • Taxpayer
    July 02, 2010 - 13:13

    Robert your job is to know what your staff is doing and to help them deal with problems. Commenting on a media site during work hours does not seem to be doing the job. Maybe that's why we have problems.

  • Evelyn
    July 02, 2010 - 13:12

    She has RESIGNED...good riddens as I don't believe a word from her mouth.

  • AR
    July 02, 2010 - 13:11

    @ Taxpayer From NL & other posters pointing fingers at Vickie Kaminsky:
    Ms. Kaminsky was not hired to micro-manage; she's the President & CEO of Eastern Health which has policies and procedures that must be followed. Was Ms. Kaminski expected to check on all the staff to ensure they read the policies and procedures ? No doubt she assumed they could read. The person held responsible has since resigned and that person, rightly so, is not Ms. Kaminski.

  • HSE
    July 02, 2010 - 13:11

    Robert I tend to refrain from finding fault in comments contained in these types of open fourms, unfortunately you failed to read between the lines. This CEO holds full accountability for any shortcomings of the system. This CEO was brought on to correct the issues by taking a leadership role and forging a productive path forward. This has repeatedly not been accomplished, but it has been replaced with blame focused on others. I feel sorry for anyone working under your guidance if you feel it best to let the crap run down and not take responsibility for your staff or department heads in the private sector as you so eloquently defend. I on the other hand have no reason to blow my own horn, my record speaks for itself.

    When managers or CEOS fail to actively participate in all areas of operation we see a complete breakdown of the system. This micro-management practice shown by far too many is a systematic cancer which needs to be weeded out before it spreads any further. If Vicki Kaminski can not be more hands on, she requires her team to follow up daily with action items to ensure quality and safety or step aside so that she can be replaced with a more competent individual.

    It appears that no written policy was current surrounding the reporting issue, but was and still is under development to be implemented at a later date. One can not be punished for not following a procedure or policy that is not current or active. Check with Labour Relations Legislation. Passing the buck is not what she is being paid for. She is being paid to ensure quality health care management for Eastern Health.

  • member of the 20%
    July 02, 2010 - 13:10

    While Ms. Vickie is clearly in over her head, there's no disputing that the culture of ineptness is still flourishing over at Eastern Health. Years of husbands hiring wives; mothers hiring daughters; friends promoting pals...has finally caught up. We need trained expertise, not the buddy system; far too much at stake here. Wait for Jerome's Tory spin on this one. Minister, you must stop promoting and rewarding Tory supporters; stop transfering incapable people from other government departments and parachuting them into health when they have no background or training. Listen to the frontline workers, health care in this province is in shambles.

  • in the know
    July 02, 2010 - 13:10

    ... I rarely agree with Nate's comments bu this time he is dead on.

    THERE ARE NO POLICY AND PROCEDURES IN PLACE for this type of thing. ALL the quality managers that were hired because of the Cameron Inquiry have yet to finish them. And EVEN IF they were finished there hasn't been enough time for staff to have been inserviced on them.

    She is passing the buck right down the line... GET REAL! You bring in a machine in 2009 and expect staff to think that something written in 2005 still has relevance?? PUT the blame where it belongs... the machine's manufacturer's had know about this for FOUR years and still installed it wrong? Stop deflecting blame to the little people Vicki. They are hard working people who certainly meant no harm in this.

  • Ed
    July 02, 2010 - 13:10

    The process to be followed 'should have' be documented and then people held responsible for their part of the process.

    Having said that, is there anyone in this province who did not get a message from the last cancer testing inquiry that we had that problems should be documented and escalated through the managament structure ASAP. Even the failure to have a completely documented process is no excuse for not reporting problems. Anyone who still needs that documented is not inteligent enough to be working on these labs and are not people I want doing tests for me or any of my family.

    Having made my comments about 'the few' people who are involved in these issues, I would like to add my comments from personal and family experience that 90-95% of the staff I have been involved with at Eastern Health are excellent employees and caring professionals.

    There, however, still needs to be a goal to weed out the 5-10% who don't measure up, and that should be pursued aggressively whether they be one of the first line staff or the CEO - no exceptions - no excuses.

  • Robert
    July 02, 2010 - 13:10

    Taxpayer, I work as a manager and as such, it is my responsiblity to be aware of and follow ALL published policy and procedures. Eastern Health's policies are not kept in a locked safe in the CEO's office - they are accessible to all that are required to follow them. If the staff managers are not doing their job, they do not deserve their paycheck - it's as simple as that.
    CEO's make the strategic decisions - it is up to the middle and low level managers to ensure that the tactical functions are carried out and that policies related to those function are followed.

  • Robert
    July 02, 2010 - 13:10

    Nate, you cannot manage without accurate information. A manager did not an existing policy. Please enlighten us on how could Kaminski have prevented that.
    The manager needs to be dealt with severely. If they are not willing or able to do the job that they are tasked with, replace them with someone who will.

  • Maggie
    July 02, 2010 - 13:09

    Nasty Nate, the armchair critic! You could probably do a better job hey old boy! You should give it a go. It couldn't possibly be that hard trying to get an old school like Eastern Health...as it is called these days...turned around.
    It may have a new name but still the same employees as forever with the same mentality and attitude...some things are very hard to start and change is at the top of that list. I'll bet Miss Vicki didn't have any idea just what she was in for when she accepted this post! I feel for her and hope she is successful in the end.

  • Willie Zoo
    July 02, 2010 - 13:08

    Vicki is being paid big bucks to do a job. Let her get in there and fire who she has to fire and get things fixed. Time to stop replacing people at the top and start making the lower managers accountable.

  • patricia
    July 01, 2010 - 20:25

    get rid of all those who can not do their jobs properly.There is too much carelessness going on and it affects those patients who are most vulnerable--the transplant patients who rely on proper analysis of their bloodwork to judge the right amount of cyclosporin the should be taking to preserve their transplanted organ.I know, because my daughter is one of them.We put our trust in the system.It can mean the difference in life and death for these patients.

  • William
    July 01, 2010 - 20:24

    its not very i agree with nasty nate, there should be only one thing happening here, instead of pointing fingers the head of this department should be shown the door for trying to cover something like up especially after the cameron inquiry, ms vickie you have internal problems

  • Member of the 93%
    July 01, 2010 - 20:19

    I worry what machine, procedure, or test will provide the next debacle. Are there people getting blood work done today, who will find out a few months from now that some dolt screwed up the process, or didn't know how to use a machine, or whatever? Ms. K. was brought here at great expense, nearly half a million a year in salary and extras, to fix a broken system. In my humble estimation she has failed. I'm sure we could have found a newfoundlander who could have failed just as well, probably for a few hundred K less.

  • AR
    July 01, 2010 - 20:19

    Its utter nonsense to point fingers at Vickie Kaminsky. She's the president and CEO of Eastern Health; she wasn't hired to micro manage and it's absurd to expect her to be aware of errors that have not been reported to her. The person(s) who did not comply with the policy regarding the submission of occurrence reports should be suspended or fired.

  • Robert
    July 01, 2010 - 20:17

    BOTTOM LINE: Ms. Kaminski was brought in at a very large expense to make sure these problems never, ever happen again because peoples' lives hang in the balance. Well, guess what, they are happening again.

  • Taxpayer
    July 01, 2010 - 20:15

    Robert if you are in the private sector then you don't know anything more about the operation of Eastern Health than anyone else on the site. So what is going on. Do you imagine that you are some kind of expert. More likely just another time waster.

  • Nasty
    July 01, 2010 - 20:15

    Stop pointing fingers Vicki. You were hired to fix the problems yet you have done very little. Your quarterly performance review shows you have failed to revamp policy and procedure. You have failed to be proactive in correcting known issues. You failed to implement the recommendations of the Cameron Report. You have failed to re-write internal work practice, policy or procedures.

    Must be nice to receive a six figure salary to do nothing more then pass the buck. Explain again just why you should remain in this position.

  • Taxpayer
    July 01, 2010 - 20:13

    Yes your right Robert. Responsibilty always starts at the bottom. What did the CEO do to ensure that all staff were aware of the procedures and that the knew they were to be followed strictly. Yes Money for nothing and your trips for free.

  • Robert
    July 01, 2010 - 20:12

    Taxpayer - I work in the private sector and what I do with my time is none of your business. I am accountable for my performance, and when that performance is below expectations, I will answer for it. This year I got a raise and a sizable bonus based on performance - how about you?

  • Andrea - Lab Tech.
    July 01, 2010 - 20:10

    gut it from nl writes: The next time I see Lab workers on the pickett line, I won't be honking my horn in support.

    If you had any clue as to what's really going in there you'd realize that 'Now' is the time the Lab workers need your support.

    We've been saying for years that there have been major problems in the labs of Eastern Health for years and no one listened. Government and Management has had us on ignore and the moment we try to pass our concerns on to the public the news media and people like you always say Oh, there goes NAPE again looking for money.

    There in lies 'your' problem; not ours. We tried to do our jobs the way we were trained and whenever we tried to voice our concerns, we were told to shut up. Dont expect us to take the blame for this frustrating and deadly mess because thats not going to happen.

  • Billy
    July 01, 2010 - 20:10

    Being totally lacking in management skills, I have absolutely nothing constructive to add to this discussion.

  • Hilda
    July 01, 2010 - 20:09

    You pay small bucks for an average manager to just fire people. You pay big bucks for a great manager to get in there and solve problems pro-actively (pro-active management = micro-management). What problems has V. Kaminski solved?

  • Lee
    July 01, 2010 - 20:08

    Same ole; same ole.
    I'm sick to death of all this blame game, neglect, pass the buck, whatever, but the bottom line is that people's very lives are
    resulting in DEATH.

  • HSE
    July 01, 2010 - 20:07

    I need to jump into the fray here since there have been points made which hold relevance.

    When I take over the management system of any new venture, I make it my personal responsibility to review all relevant documentation to ensure they meet or exceed the requirements set forth in my mandate or under legislation. Due diligence is key. If Vicki Kaminski had done this she would have been able to identify any and all deficiencies as they may have related to reporting or procedures. This by her own words was not completed.

    How is it then not the fault of the CEO in this case? To attempt to place blame on others shows great flaw in character and installs a lack of confidence in the system as a whole.

    When managers or CEOS fail to actively participate in all areas of operation we see a complete breakdown of the system. This micro-management practice shown by far too many is a systematic cancer which needs to be weeded out before it spreads any further. If Vicki Kaminski can not be more hands on, she requires her team to follow up daily with action items to ensure quality and safety or step aside so that she can be replaced with a more competent individual.

  • Mary
    July 01, 2010 - 20:06

    To Nasty Nate: If management has policy, procedures and have staff taught about what has to be done, then management has done this part of its position. There was to be a written report from the get-go. If management finds out about a month after the first verbal report, then let them discipline and keep the public informed. Nasty Nate, you must want management to micro-manage the whole of Eastern health. Too bad Nasty Nate but you are just too mean spirited and ignorant as to what management is all about.

  • Robert
    July 01, 2010 - 20:05

    Andrea - out of curiousity - is your CEO telling you to shut up or a lower level manager?

  • gut it
    July 01, 2010 - 20:02

    What a mess!

    As far as I am concerned, Eastern Health needs to be reviewd from top to bottom. Screw ups due to poor training or bad work ethic up need to be delt with by re-traing or terminations, and this means front line workers and management.

    The next time I see Lab workers on the pickett line, I won't be honking my horn in support.

  • Ed
    July 01, 2010 - 20:01

    Note to Lab Worker - Andrea....
    Who is telling you to shut up? Go around them - write a note /email to the CEO, report the problem to the newspapers, NTV, CBC.
    We are talking about peoples lives not a bad paint job on the ceiling of you kitchen or a poor repair on dent in your car door.
    Just keep in mind that those tests you are doing are for someone's mother, husband, wife or child - treat them like they were yours.

  • Gerard
    July 01, 2010 - 19:58

    Nasty Nate is right on this one and Robert has no clue. Kaminski is fully accountable to set policy AND to ensure policy is followed. If she cannot get full compliance from her staff, a job she was primarily hired to do, she has failed in her job, and as a result has proven to be an ineffective manager - a mouthpiece. The buck stops at Kaminski for her inability to effectively maintain a competent staff who follow policy. Ms. Kaminski, I would suggest you implement a policy which strongly encourages error reporting, such that your employees know in no uncertain terms the negative results of non-compliance. This is clearly where you failed.

  • Bear
    July 01, 2010 - 19:57

    When is somebody going to take the bull by the horns and fix the problems in the health system. Seems like one big mess after another. If it's incompetence, fire the whole works and start from scratch again.

  • Saucy Face
    July 01, 2010 - 19:57

    Vicki while stounding tough and thorough is only coming accross as a plant to protect the healh mininster by trying to give the finger to the ordinary lab worker following orders and deflecting blame from management where it belongs. The buck stops here is obviously not a sign you'll find on her desk.

  • Robert
    July 01, 2010 - 19:54

    HSE Manager - you contradict yourself. You expect Kaminski to ''review all relevant documentation to ensure they meet or exceed the requirements set forth in my mandate or under legislation.'', and in your next breath, you complain about micro-management causing harm to the system. You can't have it both ways.
    Kaminski has managers reporting to her that are responsible for ensuring all policies and procedures are followed. If they are not being followed, it is their duty to inform her so that she can enact remedy.
    HSE manager, if you are in fact a manager and your attitude is ''I'm not responsible to do my job until the boss finds out that I'm not doing it correctly you clearly do not understand your role and do not deserve your position. You are correct - blaming others for failing to do your job is a sign of poor character. In this case, Kaminski did hers, and you are attempting to blame her because a lower level manager did not do theirs. Hypocrite.
    Vicki - I'd agree with you if the policies were not in place but the fact is that they are; they are not being followed. No human would be able to review each policy at the department level personally and ensure that each staff member is doing their job while delivering on the other duties that a CEO has. That responsibility must be delegated out to less senior managers. Management is a team effort, and if team members are not doing the job that that they have been instructed to do, they should be disciplined. People in NL love hockey. We all know that you don't fire the GM because the team is playing poorly. You fire the coach and replace them with a better one.
    If the GM is unable to do so - that's when their head goes on the block.

  • Vicki
    July 01, 2010 - 19:53

    Robert from NL says, you cannot manage without accurate information. Thats right Robert, and Kaminski is ultimately responsible for getting accurate information through her policies, procedures and disciplinary tactics. She failed.

    Maggie from NL, Kaminski did know what she was in for ? $400,000 in salary and benefits. What completely inept person would say no to that ? Work for a year, be found unfit for the position and get fired. Wheres the risk in that ? (Like most company CEOs.)

    Kaminski is totally responsible for this mess. It is Kaminskis responsibility to lead the pack. She sets the policy and she sets the discipline. If just one of these policies is not effective, the whole system breaks down. There is no way she can distance herself from this mess since this is exactly what she was hired to do. Kaminski should have kept a close eye on these things, and if you want to call it micro managing then fine, she needed to do whatever it took to ensure this would never happen again. A good manager, a good CEO, knows all aspects of his company and keeps his ear to the ground, not in the clouds. She is paid handsomely enough to follow every step of Eastern Health. If her job was only to fire managers below her whom she blames, we could have saved a lot of money and hired a McDonald's manager. But no, we hired her, someone supposedly who could super manage this institution, and paid her well to do just that. Standing back and blaming others is not good management. For the simpler folk among us who do not understand this concept, and know nothing about management, refer to your favourite television show Dragons Den and see how real pros do, in fact, what you call, micro manage. This term is a cop-out for lazy management types who simply like to shift the blame. Kaminski should have had her focus on what she was hired to do. She dropped the ball.

  • Robert
    July 01, 2010 - 19:53

    HSE Manager - the only thing unfortunate is that you are long on rhetoric and bureauractise but short on fact. You don't need to 'read between the lines' - just read the story and stop making things up.
    ''The policies for occurrence reporting and reporting through the channels were not followed,'' Kaminski told reporters Tuesday, adding all those polices were widely distributed to staff.''It is a serious breach of hospital policy.''
    Managers were not doing their jobs.
    This issue (as reported) is not related to a system failure - Eastern Health's managers did not follow policy.
    The real cancer that affects our public service is lack of personal accountablity. Some employees get it, but too many more think 'that's not my job' and do nothing. In this case, the lab workers did their jobs and advised their managers. The managers dropped the ball and appear to be incompetent.
    Some free advice - you need to look up the term 'micro-management' - your use of the term does not support your case.

  • Taxpayer
    July 01, 2010 - 19:51

    Robert your job is to know what your staff is doing and to help them deal with problems. Commenting on a media site during work hours does not seem to be doing the job. Maybe that's why we have problems.

  • Evelyn
    July 01, 2010 - 19:49

    She has RESIGNED...good riddens as I don't believe a word from her mouth.

  • AR
    July 01, 2010 - 19:48

    @ Taxpayer From NL & other posters pointing fingers at Vickie Kaminsky:
    Ms. Kaminsky was not hired to micro-manage; she's the President & CEO of Eastern Health which has policies and procedures that must be followed. Was Ms. Kaminski expected to check on all the staff to ensure they read the policies and procedures ? No doubt she assumed they could read. The person held responsible has since resigned and that person, rightly so, is not Ms. Kaminski.

  • HSE
    July 01, 2010 - 19:48

    Robert I tend to refrain from finding fault in comments contained in these types of open fourms, unfortunately you failed to read between the lines. This CEO holds full accountability for any shortcomings of the system. This CEO was brought on to correct the issues by taking a leadership role and forging a productive path forward. This has repeatedly not been accomplished, but it has been replaced with blame focused on others. I feel sorry for anyone working under your guidance if you feel it best to let the crap run down and not take responsibility for your staff or department heads in the private sector as you so eloquently defend. I on the other hand have no reason to blow my own horn, my record speaks for itself.

    When managers or CEOS fail to actively participate in all areas of operation we see a complete breakdown of the system. This micro-management practice shown by far too many is a systematic cancer which needs to be weeded out before it spreads any further. If Vicki Kaminski can not be more hands on, she requires her team to follow up daily with action items to ensure quality and safety or step aside so that she can be replaced with a more competent individual.

    It appears that no written policy was current surrounding the reporting issue, but was and still is under development to be implemented at a later date. One can not be punished for not following a procedure or policy that is not current or active. Check with Labour Relations Legislation. Passing the buck is not what she is being paid for. She is being paid to ensure quality health care management for Eastern Health.

  • member of the 20%
    July 01, 2010 - 19:46

    While Ms. Vickie is clearly in over her head, there's no disputing that the culture of ineptness is still flourishing over at Eastern Health. Years of husbands hiring wives; mothers hiring daughters; friends promoting pals...has finally caught up. We need trained expertise, not the buddy system; far too much at stake here. Wait for Jerome's Tory spin on this one. Minister, you must stop promoting and rewarding Tory supporters; stop transfering incapable people from other government departments and parachuting them into health when they have no background or training. Listen to the frontline workers, health care in this province is in shambles.

  • in the know
    July 01, 2010 - 19:46

    ... I rarely agree with Nate's comments bu this time he is dead on.

    THERE ARE NO POLICY AND PROCEDURES IN PLACE for this type of thing. ALL the quality managers that were hired because of the Cameron Inquiry have yet to finish them. And EVEN IF they were finished there hasn't been enough time for staff to have been inserviced on them.

    She is passing the buck right down the line... GET REAL! You bring in a machine in 2009 and expect staff to think that something written in 2005 still has relevance?? PUT the blame where it belongs... the machine's manufacturer's had know about this for FOUR years and still installed it wrong? Stop deflecting blame to the little people Vicki. They are hard working people who certainly meant no harm in this.

  • Ed
    July 01, 2010 - 19:46

    The process to be followed 'should have' be documented and then people held responsible for their part of the process.

    Having said that, is there anyone in this province who did not get a message from the last cancer testing inquiry that we had that problems should be documented and escalated through the managament structure ASAP. Even the failure to have a completely documented process is no excuse for not reporting problems. Anyone who still needs that documented is not inteligent enough to be working on these labs and are not people I want doing tests for me or any of my family.

    Having made my comments about 'the few' people who are involved in these issues, I would like to add my comments from personal and family experience that 90-95% of the staff I have been involved with at Eastern Health are excellent employees and caring professionals.

    There, however, still needs to be a goal to weed out the 5-10% who don't measure up, and that should be pursued aggressively whether they be one of the first line staff or the CEO - no exceptions - no excuses.

  • Robert
    July 01, 2010 - 19:46

    Taxpayer, I work as a manager and as such, it is my responsiblity to be aware of and follow ALL published policy and procedures. Eastern Health's policies are not kept in a locked safe in the CEO's office - they are accessible to all that are required to follow them. If the staff managers are not doing their job, they do not deserve their paycheck - it's as simple as that.
    CEO's make the strategic decisions - it is up to the middle and low level managers to ensure that the tactical functions are carried out and that policies related to those function are followed.

  • Robert
    July 01, 2010 - 19:46

    Nate, you cannot manage without accurate information. A manager did not an existing policy. Please enlighten us on how could Kaminski have prevented that.
    The manager needs to be dealt with severely. If they are not willing or able to do the job that they are tasked with, replace them with someone who will.

  • Maggie
    July 01, 2010 - 19:44

    Nasty Nate, the armchair critic! You could probably do a better job hey old boy! You should give it a go. It couldn't possibly be that hard trying to get an old school like Eastern Health...as it is called these days...turned around.
    It may have a new name but still the same employees as forever with the same mentality and attitude...some things are very hard to start and change is at the top of that list. I'll bet Miss Vicki didn't have any idea just what she was in for when she accepted this post! I feel for her and hope she is successful in the end.

  • Willie Zoo
    July 01, 2010 - 19:43

    Vicki is being paid big bucks to do a job. Let her get in there and fire who she has to fire and get things fixed. Time to stop replacing people at the top and start making the lower managers accountable.