Raymond Lee Kupfer Jr. is a registered sex offender with an extensive rap sheet. But Virginia Mason Medical Center didn't know that until after the 28-year-old orderly was arrested for sexually assaulting one of its patients.
Kupfer, a contract employee, was charged with fondling the 48-year-old patient in April while wheeling her to the radiology unit, then sexually assaulting her while moving her from a gurney to a bed.
The Seattle-based hospital later learned that Kupfer was a Level III sex offender-or one at the highest risk for re-offending-with nine felony convictions, including three counts of child molestation, burglary and failure to register as a sex offender. Kupfer pleaded not guilty this month to second-degree rape and indecent liberties.
Virginia Mason has since checked the backgrounds of 200 other contract employees and fired three of them.
The incident, and others like it, underscore the small yet inherent risk hospitals face as they outsource a growing number of operations, from housekeeping, accounting and medical transcription to direct patient care.
Hospitals are fast embracing outsourcing as a way to save money, boost efficiency and improve service, said Peter Kongstvedt, a healthcare consultant and vice president of CapGemini. But in exchange, "You give up the ability to manage the hiring process," he said. "You do the best you can to ensure the vendor is fulfilling its responsibilities and you're getting the best people, but very rarely something really bad slips through."
Virginia Mason officials said they assumed Crothall Services Group, the outside agency that provided Kupfer and the other workers, had conducted background checks on each person, as is required under state regulations. "Unfortunately, the guidelines were not followed," said the hospital's senior vice president, Sarah Patterson.
Patterson declined to specify what was discovered in the other three workers' background checks, saying only that there were no patient safety issues but that "the individuals were not representative of our organization."
Crothall attributed the incident to a lapse in its established hiring process. "We always do rigorous background checking ... but there was a breakdown in the review process," said Bobby Kutteh, president and chief executive officer of Crothall, which provides facility-management services to more than 500 clients, including Cedars-Sinai Medical Center, Los Angeles; Children's Hospital, Denver; and Kaleida Health System, Buffalo, N.Y.
Kutteh said Crothall has since built additional checks and balances into its hiring procedure, including senior-management reviews of all screening results, and is now having all its background checks run by a single vendor.
Virginia Mason has also implemented a new auditing process to ensure that all of its outside contractors adhere to its stringent screening requirements, Patterson said. The hospital already runs comprehensive checks on its own workers' backgrounds, including a review of state and county criminal records of all locations in which the applicant has lived during the past seven years, she said. It has retained its contract with Crothall.
"Patient safety is our top priority," she said. "We want to make sure something like this never happens again."
Virginia Mason, however, isn't the only hospital in recent months to fall victim to a rogue contract employee.
Spectrum Health System found itself in a similar situation when one of its contract nurses was arrested and charged with sexually assaulting at least four patients at its Blodgett Campus in Grand Rapids, Mich., over a three-week period in November 2003. The 50-year-old nurse, hired through Marion, Mich.-based Critical Staffing Solutions, is now awaiting trial and could face up to 15 years in prison if convicted.
It was only after the arrest that Spectrum discovered the nurse had a history of misdemeanors that weren't listed on the backgrounder supplied by Critical Staffing.
"None of the prior violations were of this magnitude," said Spectrum spokesman Bruce Rossman. "Still, we don't feel we were provided (with) enough information."
Spectrum has since recruited a firm that specializes in background checks to thoroughly screen every contract employee and in-house hire, Rossman said.
The University of California, San Fran-cisco Medical Center was also recently forced to tighten its rules regarding outsourcing after a subcontracted medical transcriber in Pakistan-where U.S. laws don't apply-threatened to post patients' confidential medical records on the Internet in a dispute over pay.
In a convoluted chain of events, the hospital had contracted with Sausalito, Calif.-based Transcription Stat, which subcontracted the work to a Florida firm that then subcontracted it to a Texas firm that ultimately hired someone in Pakistan to transcribe the notes. In October 2003, the Pakistani transcriber sent the hospital an e-mail claiming that she had not been paid and threatening to publicize the medical records.
The subcontractor made a partial payment the following day, and the transcriber never published the information.
UCSF has since revised its contracts with transcription firms to require up-front notices of all subcontracting and requires all subcontractors to provide the Social Security numbers of every person doing the work.
"In the long run, (the incident) may not be such a bad thing because it has caused a lot of organizations to re-evaluate their outsourcing," said UCSF spokeswoman Carol Hyman. "It has opened a lot of eyes to the risks."
Outsourcing firms are quick to point out that contracting fiascos like the one suffered by Virginia Mason, while highly publi- cized, are extremely isolated events and do not reflect the quality of the industry's hiring practices.
"This is a very rare incident and not indicative of our overall service or that of our competitors," Kutteh said.
Theoretically, though, it only takes one forgotten background check to financially cripple an organization.
Take the Visiting Nurse Association, a Boston-based home healthcare agency, which in 1998 was held liable for the death of a quadriplegic murdered by one of its contract nurses. The organization argued that it should not be held accountable because it had outsourced the hiring to another agency, which didn't run a background check.
It was later discovered that the killer had never attended nursing school and had six felony convictions. But a jury found both agencies liable for negligent hiring and awarded the victim's family $26.5 million in damages.
These days, most hospitals include indemnity clauses in their outsourcing contracts to protect them from liability if a contract employee commits a crime. But such safeguards aren't always foolproof.
"Even if it's in there, it may not be enforceable," said David Manko, a partner in the health services division of the law firm Rivkin Radler, adding that liability and negligent-hiring laws differ from state to state.
"That's why," Manko said, "hospitals should always do their own due diligence."