Posted on 04/27/2008 6:52:04 AM PDT by Dysart
The waiting room reeked. Along a crowded hallway, patients lay in beds, with only a thin curtain for privacy. Nurses readying for a new case in surgery noticed blood, bone and globules of fat on the walls and floor and stuck to wheels of carts.
Chance brought to the hospital teenagers from car wrecks, fathers hurt on the job, police officers injured in the line of duty. Others -- the poor -- came because they believed they had nowhere else to go.
They were greeted last year at an overburdened emergency department where the staff could be robotic and hardened to patients. Sometimes, inexperienced nurses evaluated the sick and suffering.
Some patients were shuffled to a stifling back room to wait. Medical records, crucial lab results -- even patients -- got lost. Staff didn't notice when one Alzheimer's patient walked home in 100-degree heat. Another patient was dismissed because doctors didn't get lab results indicating a life-threatening disease.
The trauma center was described as a war zone. Operating rooms as chaotic. In too many places, instruments were broken, rooms dirty, linens threadbare.
Welcome to a hospital flush with cash and rife with problems. Welcome to John Peter Smith Hospital, hub of the Tarrant County Hospital District.
Boosted by tax funding other local hospitals don't get, JPS has been racking up fat surpluses -- nearly $97 million last year alone.
But the cash has not helped a dedicated core of doctors and nurses overcome the system's callousness, ineptitude and filth. JPS is a hospital that many of its own doctors wouldn't recommend.
In the past six years, Tarrant County property taxpayers have anted up $1.3 billion on the premise that the mission of the public hospital is to treat the indigent and needy. But a four-month Star-Telegram examination found that the Hospital District has squandered opportunities to improve care and compassion as it has chased insured patients pursued by every other Tarrant hospital.
As trash cans overflowed, so did the district's bank accounts. The district's investments swelled to $381 million last year, earning $22 million in interest. But nurses scrambled during surgeries for instruments that low-paid assistants couldn't identify.
Over five years, JPS grabbed $232 million from one federal program for the poor, and administrators said they banked much of it. Meanwhile, needy Tarrant County residents sometimes waited months for appointments, and others went without care because they could not afford the co-payments.
CEO David Cecero and other top administrators say that by improving the bottom line, they have protected taxpayers' interest and helped the hospital to meet its ever-growing burden of caring for the poor. Money from insured patients, they say, helps offset the charity care provided. Cost efficiencies, including attention to staffing levels, have also improved the financial picture, they said.
The new patient tower, expected to open next month, will help ease crowding and treatment delays. School-based clinics are reaching more and more children.
"We've expanded access, in terms of facilities, technology, locations, personnel -- both physician personnel and nonphysician personnel," Cecero said in a recent interview.
JPS' promotional campaigns make a strong case about the system's quality of care. And to all appearances, some chronic problems, such as crowding in the hospital's emergency department, have been eased.
Behind the scenes, doctors' faith in the administration has eroded. Staffing hasn't kept pace with patient load; JPS told the state that the number of full-time employees declined in 2006, the most recent year for which the data was available. Overwhelmed nurses no longer ask for the help or equipment they need, resigned to the fact that management won't listen.
"The system will transform you, so you either leave, do less than the kind of job you would like to do, meaning you have to spend less time with patients or you have to be curt because you know there is a never-ending cascade of people," said Dr. Bernard Rubin, a JPS board member and network physician.
Far from the warm friend to the community that administrators portray, JPS can be a dehumanizing place, doctors and patients say.
"We think that they make some of their profit by denying services and by denying care," said Dr. Chuck Webber, a trauma surgeon at JPS and a past president of its medical staff.
And JPS' failings, consultants have told the administration, may put patients -- rich and poor alike -- at risk.
'Where's the caring?'
Every breath was agony. Ty Walls struggled to his feet, walking through the emergency department bent over, with his hands on his knees.
The nurse he was following looked back at Walls, whose lips were blue from a prolonged asthma attack.
"Are you coming or not?"
Finally in a hospital room at JPS, the former RadioShack employee who once earned $70,000 a year was reduced to eating crackers and small cups of fruit for a day. He'd been left off the food distribution list.
The experience left him feeling like he was "one of a hundred."
Walls isn't alone -- JPS' culture can be contemptuous of dignity, privacy and basic needs, patients and physicians say. (See supporting document as PDF.)
Even Houston-based consultants hired by JPS to study the efficiency of the hospital and clinics last year were struck by the coldness.
"Where's the caring and compassion?" asked observers from InSight Advantage, which detailed hospital conditions in nearly 600 pages of reports.
The reports were authorized by hospital administrators and cost $657,618 plus expenses, but were never presented to the JPS board. The Star-Telegram recently obtained a copy.
When Cecero was asked about the reports' findings, he said he couldn't answer: He hadn't read the documents or been briefed on them.
"I don't think it's my job or my role to read every report that comes through this organization," he said. "That's why we have an executive team."
JPS board Chairman Steve Montgomery said he was unaware of the InSight Advantage study until the Star-Telegram raised questions about it. Then he asked for a copy.
"It was depressing reading at times," Montgomery said, adding that he didn't have the entire context.
But he said he was reassured by administrators that solutions were pursued on the "vast majority" of problems.
JPS has replaced equipment, made management changes and refurbished parts of the operating rooms to correct the problems, Chief Operating Officer Ron Stutes said.
"I'm bringing my mother here for surgery," he said. "I wouldn't bring my mother someplace that I didn't feel good about."
If the extensive problems were resolved in a matter of weeks, that would be a dramatic turnaround from conditions documented in the InSight report and a 2006 survey of JPS physicians. Those findings are echoed in comments by patients who, in interviews with the Star-Telegram, said they were treated like cattle.
In the emergency department, patients lacked basics such as pillows or coverings and complained about lack of information from the medical staff, InSight reported.
Some JPS doctors explained in the survey why they wouldn't recommend the hospital. "Dignity can't be present with a small room and no curtains. The ER situation impacts this; Foley [catheter] bags showing, beds against hallways, legs hanging out, etc.," one physician wrote.
At the "Rapid Assessment and Treatment" area of the emergency department, at times 45 patients were jammed into a room with chairs for 19. The space was hot and reeking. Patient privacy was not a remote possibility, InSight reported. (See supporting document as PDF.)
"What is even more concerning is the acceptance of these conditions by management and the staff," the report says.
To counter negative opinions, JPS hired patient advocates for the emergency department. InSight called that move "sad" and a waste of resources -- customer service should be everyone's job.
In the Short Stay Unit, InSight reported that some patients spent 10 days in a hallway bed, with only a thin curtain to separate them. Up to 26 patients shared one bathroom with one sink, one toilet and no shower. Patients not strong enough to go to the bathroom had to share one portable toilet.
As for basics like thermometers, wheelchairs and IV poles -- there weren't enough to go around.
Cynthia Brannon said her sister spent a week and a half in a hallway bed waiting for surgery.
"I had to come in and help clean her up," Brannon said in a recent interview. "She hadn't had a bath. ... I got her a shower cap that helps wash your hair. It didn't do a very good job. She would be laying there crying, asking for some pain medicine."
Cecero said he has heard his share of anecdotes about poor treatment and conditions and makes sure each is investigated. "But I do think that sometimes the stories become exaggerated," he said.
One incident JPS disputes involves June Kelly of Euless.
When she visited a JPS clinic in Bedford in October 2006, a woman guided her to a conference room. Kelly said she was locked inside without explanation and kept there for about an hour until a JPS police officer arrived. The entire time, she was separated from her service dog, Pumpkin, who can alert her when she is about to have a seizure.
"I feel like they treat us like we're dirt," Kelly said.
The police officer told her she was accused of tampering with her blood test paperwork, she said. Baffled and angry, Kelly said she'd done no such thing and the matter was dropped.
She later complained to JPS officials that she had been falsely imprisoned.
JPS officials told the Star-Telegram that they could not locate a police report concerning the incident, and they asked the attorney general to bar release of other records in the case.
But the Star-Telegram listened in on a phone conversation between Kelly and Pablo Guzman, the clinic's director. Guzman, who was not involved in the incident, told Kelly, "I probably [would] have handled things differently."
In April, Kelly received a letter dated Dec. 21 from John Hayes, director of guest services, informing her that a grievance committee had reviewed her allegation.
"The committee found no supporting documentation, records or statements to support your position that you were falsely imprisoned or arrested," Hayes wrote.
Reports of squalor
Golda Corley, 73, had never seen flies in a hospital before.
Corley went to visit her sister-in-law at JPS in August. Along hallways, she said, she saw urine and blood-stained beds.
At her in-law's bedside, she noticed two blankets. Both were filthy and worn out, Corley said.
"They were old, like they had never washed them from the time they bought them," she said.
She also saw flies buzzing around and under her in-law's bed."I'd rather be sick out on the streets than sick in there," Corley said.
Other patients, doctors and the InSight consultants paint a similar picture of squalid facilities:
Doctors in the 2006 survey mentioned unsightly and unsanitary conditions, including stained sheets and dirty rooms. That also raised concerns among some physicians about infection rates.
Used bandages, discarded EKG electrodes and dirty dressing gowns littered the lone shower stall in the hospital's unit for jail inmates, InSight observers reported.
Management had to beg maintenance staff to clean stretchers once a week in one department.
Dee Cantrell, a patient's wife, said she cleaned the toilet in his room because the staff wouldn't.
"A place like that, with that much money, there's no excuse," said Dr. Joel I. Shalowitz, director of the Health Industry Management Program at Kellogg School of Management, Northwestern University, when told of the concerns.
Stutes, who is responsible for hospital operations, said JPS has recently purchased new, more durable linens. The hospital has hired additional housekeeping staff three times in the past six months, officials said. The laundry system, which is 15 years old, is being replaced at a cost of $4.5 million.
Stutes said he personally tours the emergency room three times a week. And he says money is never an issue when it comes to meeting needs.
Cecero echoes the point, saying problems are attended to if employees bring them to administrators' attention. "We spent $50 million last year in capital," Cecero said. "If we needed $51 or $52, no one brought it to my attention. ...
"I have never turned down anything from anyone on any occasion," he said.
Money doesn't fix some problems. (See supporting document as PDF.)
In endoscopy, where doctors look at internal organs using a scope, a patient was treated in a room that hadn't been cleaned from a previous case. That's a serious error, said Dr. C. Glen Mayhall, who studies infectious diseases at the University of Texas Medical Branch at Galveston.
Likewise, "on more than one occasion," nurses didn't realize an operating room hadn't been cleaned until they were preparing for a patient and saw blood, bone and globules of fat on the floor, the wall and the wheels of carts, InSight Advantage reported. (See supporting document as PDF.)
Adonna Lowe, JPS' chief nursing officer, said staff was retrained after an incident came to light.
In the emergency department, floors were dirty and trash was overflowing. Mayhall said this could result in "insects and small creatures coming into the hospital."
In the corrections unit, patients with infectious diseases such as tuberculosis were accepted even though there wasn't an isolation room. That could expose other patients, staff and guards. Tuberculosis is spread by tiny droplets that dry on contact with air and remain airborne, Mayhall said.
The InSight observers also found torn and rank mattresses in the unit.
Torn mattresses can spread infections, Mayhall said, because bodily fluids can seep into the mattress, then come in contact with the next patient that uses it.
"There have been a number of outbreaks in hospitals that have been defined with the mattresses as the source," Mayhall said.
The hospital has a new policy requiring mattresses to be replaced every five years, officials said. Stained and torn mattresses are immediately replaced.
Lowe said that JPS infection rates are below national levels.
Cecero said that JPS has the best interests of patients at heart but that mistakes do happen. "When you see the volumes of patients we're seeing, with some of the inadequacies of our facility, it's going to happen. It's going to happen in any hospital," he said.
Tools and files neglected
The 11-year-old girl arrived at JPS on Jan. 25, 2006, with severe abdominal pain. Diagnostic studies confirmed an abscess of the appendix.
Surgical staff was available. An operating room was open. A bed would be waiting after the child's surgery, according to Texas Department of State Health Services documents.
But doctors did not operate on her.
Instead, JPS sent her to Cook Children's Medical Center without first stabilizing the child as required by federal law. Cook doctors immediately removed her appendix.
JPS didn't contest a $650 fine from the Texas Department of State Health Services two months later.
JPS officials said they self-reported the incident, which they attributed to an error by a doctor trainee who misunderstood the hospital's transfer policy.
Despite conditions in parts of JPS, patients can still receive high-quality medical care, say administrators and physicians.
Physicians singled out trauma services for praise in the survey. Other doctors noted that JPS had superb nurses in some facilities, such as the Family Health Center and the Stop Six Clinic.
And physicians are not unanimous in their criticism. "I've frankly been quite pleased with what I've experienced there," said Dr. Robert Capper, a cardiologist, explaining that all hospitals struggle with similar problems.
At any point along the way, though, breakdowns can jeopardize patient care.
Critical lab results -- identifying life-threatening disease -- didn't get to doctors because the message was passed through employees who didn't understand what was at stake, InSight reported.
Similarly, doctors didn't hear back from specialists, even when they were in the same building. A patient may undergo a scan for a possible cancerous mass, for example, but the referring physician never received a report. "This can have life-threatening consequences," InSight warned.
In surgery, nurses constantly scrambled from the operating room to find instruments doctors needed. "This is an unsafe practice," the report said. Equipment was scattered throughout the rooms and halls, some of it broken. No one was responsible for locating, maintaining and inventorying it, InSight consultants found.
In the emergency department, equipment was difficult to find; usable, maintained, working equipment was even scarcer, the consultants reported.
Another worry was the experience level of nurses in parts of the hospital where their roles were some of the most crucial.
At the triage area of the emergency department, some were highly skilled; they knew how to assess a patient and get the worst off to the doctor. Other nurses were on remote control. Some lacked the experience and clinical depth for the crucial decisions they made, InSight found.
In the trauma department, surgeons told the Star-Telegram that they have had to rely on temporary nurses, who may be highly experienced but are unfamiliar with JPS. "They don't know where the sponges are, the instruments are. They don't know how you like to do things," said Dr. Fernando Garcia, a trauma surgeon.
"I can't say somebody's died, but I think it's become critical, where in the back of your mind you're saying, 'This isn't the way things should be working,'" he said.
Some nurses are green, Webber said. "You have to move fast to literally save a patient's limb and/or life," Webber said. "Inexperienced people can't help you as well as experienced people."
Nor can a health network tolerate the kinds of medical records mismanagement InSight found pervasive at JPS.
At the Family Health Center, at least one out of five patients' medical records were missing. "The situation has a direct and negative impact on quality of care," InSight said.
At Diamond Hill, unfiled medical notes were stacked 20 feet high.
At the Viola Pitts/Como clinic, patient records were tossed onto shelves, some papers sliding into the charts of others.
At the Arlington Sanford clinic, some medical records were shelved in the waiting room of the pediatric area, a possible legal violation because of privacy concerns and the risk of tampering.
Consequences from medical records mistakes can be dire, said Shalowitz, the Kellogg professor. "Not only could it mean that physicians don't have information vital to patient care, it also can result in wasteful spending, because doctors may order tests that already were done," he said.
Cecero referred questions about medical records to Stutes. When asked about the disarray, Stutes referred some questions to the chief financial officer.
But he also said that steps had been taken and that JPS is moving toward electronic records.
Webber says the failings show that JPS has lost focus on patient care.
"I can't recall any discussions with the administration in the last number of years on how can we make all of these processes better and safer for patients," he said.
Cecero said that JPS has made great strides during his tenure. "What we have accomplished in the last seven, eight, nine years has been far and wide," he said. The network's strengths include emergency medicine, women's services, behavioral medicine, cardiology and cancer, he said.
"The question becomes, how much more do we need to do?" he said. "I don't think anybody has the answer to that. We need to continue to do more, and we will continue to advocate for doing more."
Online: www.jpshealthnet.org
Staff writer Yamil Berard contributed to this report.
About this series
Star-Telegram reporters Darren Barbee, Yamil Berard and Anthony Spangler spent four months examining the JPS Health Network using a variety of public records and data, including financial and tax documents, reports to state and federal agencies, and correspondence. Sources also provided the Star-Telegram with some confidential documents and with the InSight Advantage reports, which JPS had not publicly discussed or released.
The stories are also based on interviews with dozens of experts, patients, healthcare advocates, former employees and physicians, along with JPS administrators, hospital board members and county commissioners. Jeff Claassen created the online map of JPS facilities. The videographer was M.L. Gray and the photographer was Ron T. Ennis. Copy editors were Ehren Meditz and Tim Sager. Meredith Poldrack-Segrist designed the pages. Arthur Lopez provided Web design. Marcia Melton provided research assistance. Lois Norder was project director, and Danny Robbins assisted with editing.
Series at a glance
Today: Cash surpluses
Monday: Barriers to access
Tuesday: Pinched by high prices
Wednesday: What JPS says, what the records show and competing for the insured
Thursday: Gaming the system
Friday: A Q&A with JPS administrators
As a poster, you need to set context. The article does not clearly indicate what state, or even what country, we are talking about here.
You may live in Texas and know the Star-Telegram is the Fort Worth paper, but FR has a worldwide readership, and 90% will have no clue.
I know the solution! Nationalize it! QUICK! Throw more money at it!
I spent 7 years at Parkland in Dallas, arguably the sister institution to JPS. Some of this existed way back then (80’s) but I honestly don’t think Parkland was as bad as all this when I was there. However it is true that if the culture of a place is a certain way, lack of equipment, lack of staff, poor attitude, a lower social strata of patients, you do get into a certain vicious cycle - I can certainly see how that could happen.
Alabama?
Money isn’t the problem as the article spells out. We have a hospital admiration problem here.
Exactly. Alabama. Good sleuthing.
Actually, I googled JPS and Star-Telegram.
No, just quick.
There is only one Fort Worth——TEXAS, always Texas. It says right at the beginning of the article—Tarrant County. Everyone should know that.
Also, there’s a little box to click when posting articles that will show what state it’s from. One little mouse click.
If you open the link to the Star Telegram story, the top of the page says Star Telegram—Fort Worth, Texas. How much more is needed?
How much effort does it take to click the little box beside US: Texas?
I added Texas to the topics and ‘illegals’ (since the story is really about illegal immigration) to the keywords.
JPS is a cluster foxtrot—but they saved my backside so can’t gripe here.
Setting context is more than just saying what state and town it is.
The article is written for local readers. The author expects the readers to be familiar with the hospital and its position in the medical care hierarchy of Fort Worth. A local who regularly reads the paper would have some sort of general impression of what goes on at this hospital, and how it is probably funded.
"Show me just what Mohammed brought that was new, and there you will find things only evil and inhuman, such as his command to spread by the sword the faith he preached." - Manuel II Palelologus
Disgraceful! This place should be closed and its administrators brought up on charges!
Yet, at the same time, I have seen how people who make up the prospective client base of JPS go untreated not because of the system, but because they are too lazy to even try.
I know one person who would rather let his epilepsy kill him than sit in a waiting room.
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.