Part 2: Trapped in a waiting game at JPS

Second in a six-part series

The death certificate tells the end of the story. Jacob Aron Noles, age 26.

Date of death, Sept. 25, 2005. Never married, a machinist, cremated.

The autopsy tells a little more. Noles, unclad, came to the morgue in a white body bag. A Y-shaped incision was made and the heart examined. The arteries were 90 percent blocked.

Noles had gone to John Peter Smith Hospital on Sept. 24 complaining of chest pain and heartburn. He spent most of the night in the waiting room. Less than three weeks before, he'd been in the same emergency room with the same symptoms.

At JPS, nurses repeatedly suggested that the problem was all in Noles' head, said an aunt who accompanied him. So he went home.

A few hours later, an ambulance took him from his home in River Oaks to Harris Methodist Fort Worth Hospital.

Time of death, 1:25 p.m. Cause, severe occlusive coronary atherosclerosis -- hardening of the arteries.

Like Noles, many in Tarrant County -- former executives down on their luck, the working poor, the homeless -- lack health insurance. So they come to the taxpayer-supported Tarrant County Hospital District for help that other local healthcare facilities can't or won't provide.

But they may encounter barriers at every turn. What awaits them? Unbearable delays, red tape, bungling and jammed facilities. Problems that have persisted for years. (See supporting document as PDF.)

Some give up, even when their lives may be at stake.

No one would dispute that JPS does tremendous good in the community. Many patients receive quality treatment from doctors and nurses who want to work at JPS because they believe in its mission of serving the poor. Several patients at two clinics told the Star-Telegram they are grateful for the care they receive, and they were satisfied with the service.

Yet JPS' emergency department is as clogged as ever -- worse if measured by the time patients must wait for care. The crowds aren't as obvious, though -- they've been moved out of sight.

Doctors and nurses say quantity, not quality, is the JPS measure of healthcare, a concern echoed by consultants who studied JPS operations last year.

And the hospital has used cash built up from programs for the needy for facilities aimed at attracting commercially insured patients, some doctors say. Meanwhile, a $72 million fund reserved to expand healthcare for the needy was on the books for years. The board hasn't decided how to spend the fund.

Among some critics, there is a persistent, nagging belief that JPS has gone down the wrong path.

"I think the emphasis is totally on money. We've forgotten what our mission is: to take care of indigent patients," said Dr. Wayne Williams, a JPS board member.

Tarrant County Commissioner J.D. Johnson said he finds it hard to reconcile JPS' profits with its mission. "We either need to provide more services -- and I think the need is definitely there -- or give some of this money back to the taxpayers," he said.

CEO David Cecero said that during his tenure JPS has added clinics, a second hospital and a new patient tower, and it has expanded into schools.

"We've made appreciable dents," he said, though he added that with the ever-growing need, "it's like the sponge in the water glass: It continues to refill."

JPS officials said in an e-mail that they couldn't provide information about Noles' case "due to numerous federal and state privacy laws."

Two physicians contacted by the Star-Telegram and given details from Noles' medical record were divided on whether his condition could have been detected. Dr. James Atkins, a professor of internal medicine in the division of cardiology at UT Southwestern, said it would be difficult to detect in an emergency room, particularly since patients in that age range have a low risk.

Not so, said Dr. Reynolds Delgado, a specialist in cardiovascular diseases with the Texas Heart Institute near Houston. "Of course it should have been caught," he said. If blood tests for a heart attack came back negative, the patient should have been given a cardiac stress test, he said.

"That's the standard of care. That's what would have happened at my hospital or just about any community hospital. And the high likelihood is he would have been detected earlier and dealt with."

Noles' mother, Jamara McRae, believes JPS didn't make the time for her son and it cost him his life.

"I don't think they took the time. I think they had so many people coming in and they're in a hurry to push them out, so they can move to somebody else.

"It was neglect. It was."

Delays and more delays

Early last year, Romi Saenz found lumps in her breasts.

Saenz, a mother of two, spent much of 2007 balancing her worries with frustration at JPS Health Network.

Late last year, months after she first applied, she won approval for enrollment in the JPS Connection program, which provides discounted care for low-income patients.

By then, a mammogram had revealed large lumps in both breasts.

Before the lumps could be biopsied, she was told she had to get an appointment with JPS to see a physician.

She called in November and December. She finally saw a doctor in late April.

But not for having a biopsy.

That will require another appointment. (See supporting document as PDF.)

"It just takes forever," Saenz said.

Delays in healthcare are all too familiar. But Tarrant County's safety net system can move with sloth-like speed. Lack of prompt diagnosis and treatment may put patients in a crisis by the time they see a doctor. The delays also effectively cap the number of the poor in the JPS system, some have said.

"It becomes a vicious cycle for those patients who know they have a difficult time getting access to the JPS system," said Dr. Greg Fuller, president of the Tarrant County Medical Society. "So what happens is they give up before they even start seeing a doctor. When they finally get seen by a physician, it is sometimes too late to alter the outcome of what has happened to them medically."

Bottlenecks permeate the health network at every level. Patients wait weeks to get a doctor's appointment and months for some specialists, like pulmonologists. And when appointment time finally arrives, patients cool their heels for hours waiting to see the doctor.

Even in the emergency department, obtaining care may be a daylong ordeal, JPS data show.

The wait now averages about 7 hours, Chief Operating Officer Ron Stutes said.

But one of Cecero's first priorities after joining JPS in 2001 was reducing the average of 5.7 hours that patients spent in the emergency room.

"I won't admit [patients] here due to the fear that the patient will be stuck in ER for 2 days," one JPS physician commented in a 2006 survey conducted by the hospital. "This actually happened to a private patient of mine."

Ineptitude, bad management, a lack of beds, a lack of staff -- it isn't easy to pin down what is to blame for delays.

JPS administrators and the board chairman attribute delays to growing caseloads, the nursing shortage and physicians working too slowly. The first two are out of JPS' control, administrators say. But Steve Montgomery, chairman of the JPS board, said doctors need to speed up to match the pace in the private sector.

"Why can't they see more [at JPS]? Why are some of them seeing 16 patients a day when private doctors are seeing 30 patients per day?"

There's a ready answer from physicians and other staff: The health problems of the poor are far more complicated. What's more, medical care at an educational hospital, such as JPS, can take longer because the doctors in training are learning as they go.

Dr. John "Jay" Haynes, the chief medical officer at JPS, said the productivity standards do consider the patient's age and severity of cases.

But other doctors object to mandates to see a set number of patients per hour in some departments, clinics and other JPS facilities. Such quotas have nothing to do with quality of care, board member Williams said.

"It hurts quality care," he said. "And it is a mechanism whereby they can blame the doctors if there are access problems."

Some doctors attribute delays to staffing shortages and their own conflicting duties among the clinics, emergency department and surgery.

InSight Advantage consultants identified a litany of problems last year: unnecessary lab tests, housekeeping delays, broken and missing supplies and equipment, and financial incentives that trump efficiency.

Staff members say there simply are not enough hands to do the work.

Sharon Delso recently quit her job as a JPS clinic manager in Arlington after working for the public hospital system for three years. She said she was frustrated by the inability to get new patients into the JPS system. Some waited almost a year for their first appointment, she said.

"I was short-staffed on the phones registering patients and didn't have enough staff to see people," Delso said in a recent interview.

The referral process to see a specialist resulted in months-long waits, even for patients who were acutely ill, she said.

"We just tell people there is nothing we can do about it," Delso said. "They end up going to the emergency room."

Patients at the Family Health Center often stood in long lines that wound past the elevator at JPS' main campus, InSight consultants wrote. Patients frequently needed three-month follow-up appointments but couldn't schedule them then and there. Instead, they were sent appointment cards for dates that might not work for them, because they lacked child care or transportation or couldn't get off work.

At the Viola Pitts/Como clinic in Fort Worth, "It is not uncommon for patients to be rescheduled multiple times after waiting weeks for appointments," InSight consultants wrote.

At the Arlington Central clinic, there was a 33-day wait for new appointments despite the center being at half of its capacity for seeing patients.

Michelle Youngblood, a former JPS Connection patient with multiple sclerosis, said she languished on a waiting list for financial screening before she ever got an appointment -- a year's worth of delays.

Then, she said in a recent interview, daylong waits greeted her at clinics.

"I would have a 10 a.m. appointment. ... We didn't get in to see doctor until 2:30 or 3 p.m. and then still sat and waited for the doctor to come talk to me," she said. "And then I was there until almost 8 p.m. picking up my medicines from the pharmacy."

Youngblood, who has a doctorate in early childhood education, said delays were so bad "you really cannot work and access the JPS system."

After she qualified for Medicare, Youngblood said she stopped using JPS services.

Patients may fare no better when they need immediate care.

Mondays and Tuesdays were the busiest at the Urgent Care Center but had the fewest healthcare providers, according to InSight. On most days, patients started lining up at 6:30 a.m. A backlog developed within 90 minutes.

Once seated, patients waited, on average, nearly four hours to see a doctor. If they needed to be hospitalized, some waited in the exam room two to four hours for a bed.

In the emergency department, some patients were moved from the waiting area into a crowded and stuffy backroom, misnamed "Rapid Assessment and Treatment," where time slowed to a crawl. On one occasion, according to InSight, two patients gave up and left without being seen by a doctor after waiting more than five hours.

Many of those who left the room were judged in need of immediate medical attention.

The Urgent Care Center and Emergency Department competed over some patients. Quotas and doctors' financial arrangements may have been factors, InSight reported.

At nearly every juncture in the JPS system, patients stacked up waiting for beds. So they were placed anywhere JPS could find space -- the hallways of the short-stay unit; the post-anesthesia recovery room; the emergency room. That created a domino effect of delays.

In surgery, few operations began on time. Nurses were busy finding instruments and stocking supplies or doing secretarial jobs. Perhaps predictably, the patients weren't ready for surgery when a room opened up. (See supporting document as PDF.)

Surgeons were chronically late anyway. Some were overseeing two or three operations at a time. Others had conflicting duties between clinics, the emergency department and the OR.

"These attempts to meet all of these duties result in poor or delayed patient care," the InSight report found.

Once in an operating room, things slowed even more. The operations manager ran around trying to find missing equipment and instruments. Nurse assistants, tied up transporting patients, weren't checking the operating room and making sure needed supplies were available. Even when surgery was completed, patients waited. (See supporting document as PDF.)

They couldn't be moved to the post-anesthesia unit because it was filled with nonsurgical patients waiting for a hospital room.

Overloaded call center

If the delays that permeated the JPS Health Network weren't discouragement enough for patients, its bureaucratic comedy may have been too much.

For the sick and the injured, none of it was funny.

At the Viola Pitts/Como clinic last year, signs pointed to a place for patients to sign in. But there was no place to do so. Another sign told patients that if they had not been called in 20 minutes to ask the person at a window for information.

The problem? No one was sitting at the window, wrote consultants for InSight Advantage, which reviewed operations last year.

Another runaround: When patients called its pharmacy for refills, they were told they didn't have any and should call their doctor. So they called a clinic, where someone talked to doctors and pulled and reviewed medical records. Often, a nurse found that the patient had several refills left.

The result: The patient is told to call back the pharmacy.

The phone systems at JPS also left much to be desired. Phone lines at the Arlington Sanford clinic didn't allow employees to dial the 682 local area code.

Last month, social workers complained at a public meeting that they couldn't get through JPS phone lines at the primary call center or clinics to make appointments.

Even doctors had phone problems, InSight reported: Emergency department physicians trying to reach a patient's primary care doctor had to go through a switchboard. Often, they were put on hold 10 minutes or more.

And in 2007, at least, JPS' primary call center was a mess. On Mondays, the system was flooded with calls -- the same day the center was staffed lightest.

Many calls were from patients trying to schedule appointments at the Family Health Center or another clinic because they couldn't get through. But the call center couldn't schedule specialty clinics, so it had to transfer the calls.

Another major hiccup: a 20-caller limit. Once that many were in the system, anyone else fell off and their calls never got answered, the consultants found.

It's unclear if the system has been fixed. JPS officials said that the center has a 20-line limit and that calls go to a queue.

But officials said in an e-mail to the Star-Telegram that "Customary call volume does not reach the 20-line limit."

"We've actually reduced our call abandonment rates," said Ron Stutes, JPS chief operating officer, in a recent interview.

Registration systems at various clinics encouraged patients to jump the line, causing backups.

The Family Health Center wouldn't take patients from the Urgent Care Center if doctors thought the case was too complex.

The staff at the Urgent Care Center didn't know about JPS services and gave patients outdated information.

Throughout JPS, there wasn't a single location or publication with information about its numerous clinics or services.

JPS hadn't done an outreach campaign.

Tarrant County Commissioner Roy C. Brooks said the Hospital District needs to do just that.

"It needs to engage in community education so people are aware of what services are available and how you access them," he said.

Online: www.jpshealthnet.org

Staff writer Yamil Berard contributed to these reports.

HITCHES IN THE SYSTEM

Patients face lengthy waits throughout the JPS Health Network, a problem that has persisted for years at the taxpayer-supported public hospital. Reasons are numerous, but they boil down to some common factors. Here are 10 triggers for backups cited by consultants in a report to JPS last year.

1. The hospital doesn't have enough beds, so patients stack up throughout the hospital.

2. Medical records can't be found or aren't up to date.

3. Medical equipment and instruments are broken or in short supply.

4. Doctors are juggling work in clinics, the operating room, hospital rooms and the emergency department.

5. Some nurses lack experience or are diverted to hunt for supplies.

6. At peak times, there's not enough staff.

7. Some employees lack the skills or are otherwise unable to do their jobs.

8. It takes too long to clean and ready operating rooms and hospital rooms between patients.

9. Doctors don't get timely consults from specialists or crucial results from labs.

10. Inadequate phone systems, a limited window for scheduling appointments and communication problems between the clinics and call centers make it difficult to get in to see a doctor or talk to a nurse.

JPS WAIT TIMES IN 2007

3 hours, 45 minutes: Average time patients in the Urgent Care Center waited to see a doctor

2 to 4 hours: Time patients who needed to be hospitalized might have waited in an exam room at the Urgent Care Center

5 hours, 55 minutes: Average time patients spent in the Emergency Medicine Department. The average is now close to 7 hours, a hospital administrator said recently.

23 hours: Average length of stay in the Short Stay Unit, a holding area when there are no beds available in the hospital. Patients may stay in the unit up to 10 days.

All night: Time Short Stay Unit patients might wait for pain medications

Source: InSight Advantage reports, based on JPS data and staff interviews

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.

At star-telegram.com/jps

Undergoing surgery? An interactive graphic shows that at

JPS it's time to wait and wait and wait.

Watch as Jamara McRae shares her belief that her son would still be alive if JPS had shown him more compassion.

Share your thoughts.

Series at a glance

Sunday: Cash surpluses

Today: 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