The “Joint Commission” Takes Action

The Joint Commission is charged with ensuring the highest quality standards at America’s Hospitals. When Pam was being processed through the Johns Hopkins meat grinder, I threatened various officials that I would report them to the Joint Commission. They laughed – said the Joint Commission was “a joke.”

I didn’t believe that – until I told the the Joint Commission Pam’s story:

Health Care Complaint:
Physician: Hugh G. Calkins, MD
Hospital: Johns Hopkins, Baltimore
Nature of Complaint:
Breach of ethics and standards of care, fraudulent concealment of records. See attached.
Thank You,

Dan Walter

Here is the reply:

Dear Mr. Walter:

I am writing in response to the issues you communicated to the Joint Commission on Accreditation of Healthcare Organizations (“Joint Commission”) regarding an organization.

Since you did not indicate the address of this organization, we are unable to locate it in our files so we can determine whether or not it is currently accredited by the Joint Commission; therefore, we are unable to take further action regarding your concern…


Office of Quality Monitoring

For the Record:

Johns Hopkins Medicine
600 N. Wolfe St.
Baltimore, MD 21287


Dr. David L. Nahrwold, incoming Joint Commission president, has promised to look into the situation.

Our correspondence follows:


March 25, 2008

Dr. Nahrwold,
I would like to thank you again for taking an interest in this matter. I know it is no small thing when you must have such demands on your time and attention.I have enclosed some of my correspondence from last year with JCAHO.As yet I have not been able to locate copies of my original complaint, which was filed more than three years ago. However, I have attached a copy of my complaint to the state medical board, which is essentially the same.Although my wife was subject to the numerous transgressions laid out in the attached complaint, the correspondence below relates to a specific point, which is the concealment of records.
We were told that Hugh Calkins would be performing all vital aspects of a cardiac catheter ablation. After a “complication” occurred, Hugh Calkins told myself, my wife and no fewer than three other family members that he – Hugh Calkins – was manipulating a Biosense Webster Lasso Mapping Catheter when the catheter became entangled in the mitral valve muscles of my wife’s heart.Here I quote from the attachment:

“On the evening of March 29th, 2002, Hugh Calkins signed the official procedure report stating – for the record – that he, Hugh Calkins,had performed the procedure. On July 28th, 2006, I inadvertently received a new set of Pamela Walter’s medical records from Johns Hopkins Hospital. Two years previous, the hospital had produced an affidavit from the head of the records department swearing that all records had been produced. However, among the records received in July 2006 was a memorandum from Hugh Calkins in which he states that “Richard Wuwas manipulating the catheter at the time that the catheter became entrapped in the mitral valve.” The memorandum is dated May 23rd, 2002. My wife and I made no fewer than six requests for the full record. Documentation will show that largest set of what was sworn under affidavit to be the complete medical record was received in June of 2004 and was comprised of 742 pages. The set of records received in July of 2006 was comprised of 749 pages. There can be no dispute that sometime between June of 2004 and July of 2006, the medical record was tampered with.”

When I asked the records clerks at Hopkins how it was that seven pages of a patient’s chart could have been added some four years after the fact ( after the statute of limitations for legal action had passed) I was told how the system works:

Whenever a request for records comes in, the records office contacts the office of each physician involved in the patient’s care. I made no fewer than six requests for Pam’s full records, and each time when Hopkins records office contacted Hugh Calkins, he provided what he claimed was the full record of Pam’s care.

However, documentation shows that when Hopkins’ lawyers asked the records office for Pams’ records in 2005 – an internal request made after the statute passed – then and only then did Hugh Calkins provide a note to the medical chart, a note which was written in 2002, in which for the first time he reveals that “Richard Wu was manipulating the catheter” at the time it became entangled in the mitral valve.

There is clear and unequivocal documentation that Hugh Calkins withheld a medical chart note for more than three years — until after the statute of limitations had passed for any legal action.

Let me repeat: It is a proven fact that Dr. Hugh Calkins withheld information from a patient’s medical chart.

This is what I laid out to the Joint Commission on more than one occasion.

Let me know what else I need to do, what documentation I need to provide – and I will do it.

With all due respect, Dr. Nahrwold, now it is up to you to act – and prove Hopkins wrong about your outfit being “a joke.”


On 3/14/07, <> wrote:

Regarding: The Johns Hopkins Hospital
Incident #4775QHO-6898ZXM
Dear Mr. Walter:

This is to inform you that we have completed our review of your letter regarding the above organization.

Based on The Joint Commission policy, we are unable to evaluate issues greater than three years old. Please be assured that although no action could be taken at this time, this does not mean that we do not view your issues as important.

Per our Public Information Policy, the following information is provided upon request as it becomes available:

  • The number of standards-related written complaints filed against an accredited organization that have met criteria for review
  • The applicable standards areas involved in a specific complaint review
  • The standards areas in which requirements for improvement were issued as a result of complaint evaluation activities
  • When an unannounced or unscheduled survey is based on information derived from a complaint or public sources, the standards areas related to the complaint
  • Any determination that the complaint is not related to The Joint Commission standards

In addition, you may also wish to refer to the organization’s Quality Report, which is available at The Joint Commission’s web site (, and click Quality Check), to obtain general information about the organization’s performance on key quality measures. To obtain a hard copy of the report, please contact our Customer Service Center at (630) 792-5800 or write to the Customer Service Center at

Customer Service Center
The Joint Commission
One Renaissance Blvd.
Oakbrook Terrace, IL 60181

The Joint Commission stands ready to receive and review issues of concern about accredited organizations at any time and will act in accordance with all the information that is provided to us.


Ms. J. Stovall
Office of Quality Monitoring

———- Forwarded message ———-
From: Dan Walter
Date: Wed, Mar 14, 2007 at 6:35 PM
Subject: Re: Issues Older Than 3 Years Email
To: “” <>

March 14, 2007
Ms. Stovall,

This issue is not greater than three years old. I am telling you that Hugh G. Calkins, MD withheld a document from the medical records until last year. The medical mistake occurred more that three years ago, but a medical chart note indicating that a trainee was performing primary aspects of the procedure without my wife’s consent was withheld until July 2006.

Please let me know what other documentation you may need.

Thank You,
Dan Walter


PS… Here is another incident report # 5319 ASQ – 1442SAC

23 Responses to The “Joint Commission” Takes Action

  1. Dr.Nohrwold,

    You need to understand WHO The Joint Commission really is!

    Dr James Goldberg

  2. Hello Again,

    Complaining to the Joint Commission is a futile activity: they are crooks….in it for the money. Lodging a complaint with them is like asking the Pope to convert to Juadism!

    Read my books and website: I have investigated these b….tards for the last several years and have had personal contact with them.

    They are NOT your friends. And, to boot, they are tax exempt, which means that the taxpayer gives these crooks in Oakbrook, Ill, a free ride. They need to be put down!

    Dr. James Goldberg

  3. I never heard if this 3 year statute….have you seen their by laws and give reguations?

    Dr James Goldberg p

  4. Please call me. I want to help!

    415 755 5711 cell

    Dr James Goldberg

  5. James Goldberg: contact at

    Please note the correction.


    Dr. James Goldberg

    • Anonymous says:

      Thanks for your information I won’t waste my time I was treated like a dog at the hospital in a car accident whith a broken ankle bleeding from the head wich they didn’t do a exray of and I’m disable I walk with a cane or a walker they put the roung kind of case on my foot and sent me out the door dedent even give me a crutch no paper work and hand me over to police if you are black don’t never go to Clark regional hospital in Winchester ky I am handicap was in a car accident and this is how I was treated so fuck joint commission .thank you

      • James Goldberg says:

        The Joint Commission is a complete scam….you will NEVER get any relief through or with them. They are in business for the $$$$.

        • Diane Wagner says:

          I was just fired by these criminals and they were pretty horrible.
          I am not doing well after the encounter. I was hired to fill a physician shortage but found corruption. It has nothing to do with quality of care but only about greed and profit and let’s not forget sexual harassment and abuse of power.
          I was never reimbursed for my work travel after spending hours online with their sick accountant who wanted me to call him at 530am when I was on site at a hospital inspection.
          When I asked for his supervisor after my expense report was rejected 7 times then the leadership decided to retaliate when I traveled 20 hours during snowstorm to “help them “ because they needed doctors.
          They don’t need any doctors because they are sick.
          There are better jobs out there and
          You were right.
          They were missing 500,00 from the budget last year and the accountant brags that 50 percent of expenses are never even submitted for reimbursement.
          And why is that? Where is the quality check and maybe he should be audited.

  6. Renee Obey MD says:

    It is disappointing to read the experience of Pam and the comments of the posters regarding the Joint Commission. But, as a physician who has always practiced competent and clinically prudent medicine and who has always followed her moral compass, I am afraid to say that eventually there will be no physician who is a patient advocate and committed to quality care practicing medicine. That is because the outspoken doctors are being blacklisted out of the industry and those who want to do the right thing and who are clinically proficient to do what is proper will be so consumed with the fear of being retaliated against that they will feel forced to keep their mouths shut if they want to continue to practice medicine. When we finish medical school we pledge an oath called the Hippocratic Oath to do no harm. In reality we are told that to protect our careers we must report no harm. I realized something disturbing was going on in healthcare when I was ostracized as a resident for trying to take proper care of patients. Nurses would mismanage a patient that would lead to an adverse outcome and I was to say nothing. It is not in my nature to keep my mouth shut when I my name, reputation and license are involved. Having courage is an attribute I possess but many lack. I understand the fear that healthcare professionals have because money talks in corporate United States of America. As such BS and crooks will walk as the line the pockets of dishonest lawyers, judges, politicians as well as dishonest healthcare providers. Most doctors realize that in the times of declining physician reimbursements being politically connected to a hospital and protecting that hospitals bottom line will line their pockets. I am a primary care physician and most of us will never make enough to retire. The days of owning two homes, a yacht, a plane and to be able to shop limitlessly are gone UNLESS you are a corrupt physician. If you are making decent money honestly you are killing yourself to do it and surely do not have a quality of life. Doctors now know as with other corporate entities that if you can’t beat’em, join’em. It’s the American way and reason I am strongly considering raising my children in another country. I certainly will not teach them that the way to success is to be dishonest and to step on the backs if others, but with the way the corporate system is set up that is exactly what you would have to do.

    As an honest physician, I have found myself a target almost the entire time I have been in healthcare. The power that hospitals have was afforded to them by the government through a law called the Healthcare Quality Improvement Act of 1986. Although this law purported to improve the quality of healthcare for patients, the only thing it really did was poise hospitals and their lawyers to be in a better position to cover up their mistakes. This law gave absolute and unregulated power to hospitals any anyone on their payroll. It gave hospitals weapons to use against physicians to effectively silence them if they cannot control them. The best doctors will speak up. The mediocre doctor as well as the corrupt doctor will be easily persuaded. I believe the biggest mistake patients make is to not be empowered to know every detail about their care and to believe that the highest ranked hospitals in the country who purport to have the best and highest skilled clinicians are immune to corruption. When protecting the bottom-line is the primary agenda for any hospital administration that will be at the expense of quality care as well as at the expense of honest behavior. I was a physician in Texas specifically Plano and Frisco, affluent suburbs of Dallas for many years. It was one of the most corrupt areas that I was unfortunate enough to practice in. After enduring many years of a use at the hands of Texas Health Presbyterian Plano and Baylor Medical Center at Frisco for not condoning their corrupt behavior, I decided to relocate. Just so you know when hospital can’t control the honest and competent doctor, they try to label them as disruptive or impaired as the this may be the only way to effectively eliminate them. The laws and policies are set to allow hospitals to effectively label nonconforming physicians in such a way that will prevent them from practicing anywhere in the country again. And besides the government, guess who else gave hospitals to destroy the competent and morally conscientious physician? You guessed it, the Joint Commission!/ All doctors know this so those who want to do the right thing keep their mouths shut and look the other way. But, to me these doctors are just as dangerous and just as culpable.

    The healthcare industry is a literally mess because of the corporatization of healthcare. Thousands of patients die every year because of errors made that are effectively and successfully covered up. It is not only ethical physicians that are victimized when they try to protect you from harm but ethical nurses too. As it stands and after spending half my life and accruing a lot of debt from studying medicine, I no longer desire to work in an industry where I am being forced to pretend as if I am practicing medicine. The harassment and abuse I am subjected to is just not worth it especially when I know there is no due process for physicians like me. I will leave healthcare with my integrity intact. In more than 15 years in the industry, I have never had an adverse outcome due to negligence or incompetence. I have never had a malpractice claim file against me. This is because I try to remain humble and to do my best everyday to do right by those who trust their lives in my hands. That has not stopped unscrupulous hospitals from trying to destroy my life and that of my children because in their despicable minds I am a threat to their bottom line. It is my passion to expose them. I currently have legal action against Baylor Medical Center at Frisco. They are guilty of egregious behaviors. Their CEO, William Keaton and the Vice President of Medical Affairs, James Laferney are guilty of abhorrent behaviors that are earning them millions. The physicians politically connected to them are being paid stipends in addition to their base income to behave badly. I just filed a complaint with the Joint Commission against both Texas Health Presbyterian in Plano and Baylor Medical Center at Frisco. Both hospital are bad behavior that have injured patients who have gone to their hospitals. Both are politically connected these “corporate” physicians control both hospitals. These factors have rendered the environment at these hospitals unsafe clinically and extremely hostile to the physicians who want to remain your advocate. If the Joint Commission does nothing about the activities these hospitals are engaged in it wouldn’t surprise me. It will just prove how disgustingly broken the healthcare industry is. To all patients I say stay empowered to know every detail about your health and the care being afforded to you. Always ask questions and expect legitimate answers. Hold EVERYONE in healthcare accountable for their action from administrators to doctors and nurses. Finally know that dishonesty and bad behavior exist in most hospital in the name of the “bottom-line”. Billions of dollars are at stake so to Administrators and corporate doctors you, the patient, and ethical providers become merely loose ends.

    I revealed my name to remain transparent. I do not fear rebuke or retaliation from these dirty rotten scoundrels and I look forward to exposing them. They may have the money and power on their side to get their way, but unlike them I have the truth on mine.

  7. Anonymous says:

    I am a Quality Assurance Consultant.
    Our medical profession’s ethice and morals are disgusting.
    I sent a registered letter to St. Jospeph Mecy Hospital in Howell, Mich. about (10) years ago reporting that a Nurse Manager suggested to a nurse that she destroy a patients’ record.
    Guess what? No reply.
    I then called St. Jospeph Mercy Hospitals Pam Otto August 2013(Patients relations).
    Told her of the attempted cover up and that I wanted a meeting with St. Jopseph Mercy Health System’s’ CEO. guess what? No reply. After having several phone conversations with Pam Otto, she reused to allow me to speak to her superior’s. She contacted security and they accused me of harrassmant and issed a No Tressapas Notice.
    This is what happens when sin is on the run. When truth comes, sin runs. The medical profession will either throw a lawyer in front of you or a security person in an attempt to cover their sin.

    I asked for a copy of all my complaints and any corrective/preventive actions taken to address those complaints.

    Guess what?

    No reply.

    What is so diasppointing is St. Joseph Mercy Health System (Which is run by Trinity Health) is a Chririian Mininistry.

    Unfortuanately, the great nuns that run Trinity Health are not aware that their Executives are behaving like HEATHENS!!!

    August 16, 2013

  8. Katy says:

    He Dan-
    as everyone suggests – hanging in there with your online blog and “Collateral Damage” book is more effective than any so-called “agency” that pretends to protect the public and discipline hospitals or doctors.
    They expected you and Pam to give up and go away– and you didn’t
    [My investigation into illegal medical research is still ongoing and the results are so shocking, I hope to offer it one day toCNN
    I do not blame the entire medical profession but media exposure is the ONLY thing that certain medical low-lifes fear]

    We have to remember that our complaints to agencies proposing to protect patients have little effect. It is THEY who write the standards manuals and quite obviously in favor the institutions and the doctors. These manuals are also a clever defense tool for a doctor’s or hospitals’ lawyers –

    The PUBLIC never gets to provide input or vote on these manual’s rules – [perhaps writing to our legislators about this?]

    I recently read an online statement by one such agency director who said something like — not a direct quote:
    “Researchers need to realize that we have injected “flexiblilties”into the research regulations which if followed can be used in their favor. ”

    My take on this is that any adverse decisions by the agency MAY have beenbased on their lack of using these flexibilities – and were there own doing–

    In other words we’ve got YOUR back NOT the patient’s so use the tools we gave you!
    Corruption? Maybe not…Bias? For sure

    Patients are the enemy once they are injured – and they face a battlefield of codes, laws etc designed for the medical profession to prevail in dismissal of damages.

    i.e.. As Dan so aptly phrased it – COLLATERAL DAMAGE
    Because like it or not, we are ALL viewed as “potential collateral” damage even BEFORE we are even treated.
    Their defense was already in place before you hit the ICU

  9. Sally Strope says:

    I know of one ranking by U.S. News & World Report that makes me think its rankings are journalistic malpractice.

  10. Ed says:

    I reported Kennedy Health System Cherry Hill, NJ Divions Emergency Dept for eggregious activities pertaining to painfully poor medical care. Joint Commissions investigated and nothing was done to see that the physicians involved received oversight, reprimands or revocation. It was astounding!!!!

    Joint Commissions is a business to make money. They have no interest in supporting excellence in patient care. Its all about JC getting that check from the hospitals followng the survey. I frankly think JC can be paid off with bribes to look the other way.

    The news media would have to be involved to get patients justice for eggregious healthcare activities. Then (maybe) JC would actually do the right thing.

  11. Anonymous says:

    I would report this issue to Senator Ted Kennedy and to Senator Grassley. I would also wait for the Cabinet appointment of Tom Daschle to report this issue again for the OHHS.

    The cover-up is out of the arrogance of academic medical centers who think they are above the law and above the rules of basic human respect.

    Medicine was once a respected profession and now it is has become a money and ego oriented business practice that places like Hopkins and others are in for a major reality check for not even doing the obviously right thing for this patient in the beginning and not not taking care of the outcomes respectfully. The cover-up will soon be uncovered.

  12. Lori says:


    Hmmm, it seems The Joint Commission might have a form letter circulating about their 3 year statue of limitations……my initial complaint was indeed filed within the three year limit also, but when I sent them a letter back explaining this, no one ever responded.

    What I did find out was that they had just completed the hospital’s on site visit and accreditation–and of course it passed with flying colors…….maybe they didn’t want to have to put a retroactive red mark in the column that reads: “You are required to disclose medical errors that cause harm or death to your patients.”

    Here’s their letter to me:

    This is to inform you that we have completed our review of your letter regarding the above organization.

    As noted in our website, The Joint Commission does not conduct individual case management, nor do we conduct peer review. Since participation in Joint Commission accreditation is voluntary, regulatory oversight for this facility ultimately rests with the state (Department of Health) agency, which also acts as an agent for the Centers for Medicare & Medicaid Services.

    Based on Joint Commission policy, we are unable to evaluate the clarifying information you recently submitted, as these issues are over three years old. Please be assured that although no action could be taken at this time, this does not mean that we do not view your issues as important.

    Per our Public Information Policy, the following information is being provided to you:

    The number of standards-related written complaints filed against the above named accredited organization that have met criteria for review: 4
    The applicable standards areas involved in a specific complaint review: Rights & Ethics, Assessment and Care/Services, Medication Management, Communication
    The standards areas in which requirements for improvement were issued as a result of complaint evaluation activities: N/A
    When an unannounced or unscheduled survey is based on information derived from a complaint or public sources, the standards areas related to the complaint: N/A
    Any determination that the complaint is not related to The Joint Commission standards: N/A
    In addition, you may also wish to refer to the organization’s Quality Report, which is available at The Joint Commission’s web site (, and click Quality Check), to obtain general information about the organization’s performance on key quality measures. To obtain a hard copy of the report, please contact our Customer Service Center at (630) 792-5800 or write to the Customer Service Center at

    Customer Service Center
    The Joint Commission
    One Renaissance Blvd.
    Oakbrook Terrace, IL 60181

    The Joint Commission stands ready to receive and review issues of concern about accredited organizations at any time and will act in accordance with all the information that is provided to us.


    John Michael Delacruz
    Office of Quality Monitoring

  13. Anonymous says:

    I agree with you that the “Joint Commission” is a “joke” — but obviously, it is a “joke” because it is joining with the liar(s) to help them (him-HC) cover up his lie and incompetence.

    “Dr.” HC – stand up and be a MAN and admit your wrongdoing! If you are a Christian, you know it is the RIGHT THING TO DO! And if you are any other religion (I only know about Christianity), probably it, too, would urge you to do the RIGHT THING: TELL THE TRUTH!

  14. Grandma Sarah says:

    Dan and Pam,
    So sorry about what you are going through! I have had two cardiac RF ablations and three EP mapping studies. I know from whence you speak.

    What happened legally? Did you have any recourse through a law-suit? I know that fighting this with lawyers, does NOTHING to change the torture you’ve been through, does it make up for….well, much of anything!

    However, it almost sounds like an “ethical duty” for you to pursue this in the realm of the courts, rather than just allow the doctors and hospitals to go unchallenged. I too have had some bad experiences in a “top ten best hospital” but nothing as horrific as Pam’s. I also have been involved in a medical malpractice lawsuit for the past four years, and it’s not over yet.

    Hang in there. Too many people don’t have the energy, or tenacity to follow through, and what YOU are doing, may just help someone else in ways you’ll never know.


    Grandma Sarah

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