JPS officials respond to criticism

In a series of interviews, JPS Health Network administrators and board members answered questions on topics such as staffing, rude or disagreeable treatment of patients, and quotas set for doctors. They also addressed other concerns cited in reports by Houston-based consultant InSight Advantage, including unsanitary conditions in parts of John Peter Smith Hospital.

Here are highlights:

How do you respond to the criticism from outside consultant InSight Advantage that there is a culture of callousness permeating the JPS staff?

JPS board Chairman Steve Montgomery: "What I hear is that we do a really poor job at customer service. There are patient care issues, yes, we could always do better. But it is an issue of treating everybody respectfully regardless of whether they drive up in a Mercedes or have to walk across town to get to us. I really think we don't do as good of a job, maybe it's part of the culture, frustrations or other things."

In numerous instances in the InSight report, concerns are raised about infection-control issues. There are examples of nurses preparing operating rooms who saw blood and bone fragments in a room they thought was clean. How did situations like this develop?

JPS Chief Nursing Officer Adonna Lowe: "Obviously we all want the environment to be as clean as can be. We don't do surgery on the floor. So that would minimize some risk. ... But there is no doubt, our operating rooms, built in 1969, have been stressed with the volumes that we put through them. What they were pointing out were specific unique situations that have occurred. But most of those have occurred because of the volumes going through our facility. Trying to turn a case quickly to minimize delays opens you up to missing some steps."

CEO David Cecero said he had not read or been briefed on the InSight Advantage report and, in fact, knew nothing about it. Why was it that the CEO was not made aware of the findings?

Chief Operating Officer Ron Stutes: "Did we sit down with that big book and go over it with him, the answer is no. I have shared bits and pieces of the report in various meetings with him. If you look at the documents, most of the projects that we have taken to the board have had their genesis in the InSight report."

Did you share the InSight Advantage reports with the JPS board of managers?

Stutes: "We didn't sit and go over the whole report with them because it is more of an internal operating document."

What deficiencies identified by InSight have been addressed?

Stutes: "We've done equipment replacements. We rebuilt the pre-op areas and part of the ORs. We made a number of management changes such as medical records in the [Family Health Center]. ... There are some issues that will be addressed by moving to the new patient pavilion."

Patients described being treated with a lack of dignity, whether it was a woman who spent her entire stay in a hallway and for nearly two weeks was not given a bath, a man who was left off the food distribution list and sustained himself on crackers and a fruit cup, or a woman who was locked in a room for an hour. Are employees overwhelmed because of demand?

Stutes: "We have been doing some assessments and interviewed the doctors to ask what do you need that you don't have today. We are adding more social workers, case managers ... [medical assistants and nurses] as a response to that. We have achieved double-digit growth and we have to re-evaluate. ... We have had a shift in this community and had significant increases in trauma cases and clinic visits. The question is, what are we going to do if this trend continues?"

The InSight report says that the JPS staff is reluctant to talk with management about problems because they don't believe the administration will be responsive. How do you change that?

Stutes: "Part of the reason we are making management changes is to make sure we have managers who employees feel comfortable talking to. ... I roam the halls two or three times a week, and employees are not afraid to talk to me, and they do."

According to InSight, JPS staff doesn't have enough equipment and too much that is broken. Nurses sometimes have to leave surgery to find instruments. How did those problems exist? Did you ask to spend money to address these issues?

Stutes: "There are so many nooks and crannies that they often have difficulty finding things. We determined we had some lax management, and we have corrected those issues. We let Dave [Cecero] know how much we need over the year for capital expenditures. ... Some of these smaller items are harder to keep up with because there are so many places where they might be. ... There is no dollar shortage. We spend $35 million a year on major and minor equipment."

What are your concerns about setting quotas for the number of patients that your medical staff should see in a given time period?

Chief Medical Officer Dr. John "Jay" Haynes: "We have a mission to make sure we do what's necessary to improve the health of patients. The productivity is different depending in the acuity of care, depending on what presents at the time. ... The direction from our board of managers is to improve access and try our best to decrease delays. We've tried to establish patient ratios and work with physicians, looking at what would be minimum expectations of their workload and our capacity of the clinics and the capacity that the physicians have."

In critical areas of the hospital, some JPS nurses lacked experience. How does that factor in to quality issues?

Haynes: "We have a shortage of nurses. We tried to have an extensive orientation with every nurse who comes on board. Because of retirements or nurses moving on, we have to hire part-time or traveling nurses. Sometimes it has a steep learning curve. I'm not particularly aware of any case that it has impacted quality."

Is preferential treatment given to commercially insured patients for operating rooms?

Chief Executive Officer David Cecero: "We don't give any preferential treatment to any patient. We have hopefully one standard of care throughout the system. And that's a positive, appropriate gold standard in the system."

Some critics say that delays that patients face in obtaining care are a way that JPS limits use of the hospital by the poor. How much of a priority has it been for the hospital to address delays?

Cecero: "I think, by expanding all clinics that we've added over the last several years -- the Women's Centers didn't exist. Now we have three. The Cancer Center, if you were to go up to old unit seven years ago and saw it had four chairs for chemotherapy patients. Now we have a free-standing cancer center. ...

"We have a beautiful radiology department now today, and it's serving the needs extremely well. We're continuing to add to technology at every turn. ... Over the past several years we're spending upwards of $40 to $50 million on capital and technology to help meet the growing needs of services.

"It serves no purpose to have delays and have backups. The question just becomes, 'What is the volume that we're going to be handling?' and that number continues to escalate."

Some JPS patients have related disturbing stories about their experiences. Some say these stories leave the impression that JPS, while profoundly adept at maximizing the bottom line, cannot deliver the basic essentials of care. What do you believe the public should take away from these examples? What do you do, as administrators, when cases such as these come to your attention?

Cecero: "I wish I had the specifics of the examples because I would personally research each one. Where there's family involved, I would be willing to talk to family and find out the specifics. ... I'm not saying what you're saying is inaccurate or untrue, I don't know. But I have heard a lot of examples, of things like this, and when I investigated them or evaluated them or had either Adonna [Lowe] or Ron [Stutes] or others, I find oftentimes other things that make that not as accurate as sometimes being depicted. I'm not saying we're not human, and we're certainly not infallible. We will make mistakes but never by consciously making mistakes."

According to a survey, a majority of JPS' own physicians wouldn't recommend this hospital. Some physicians have told us that the quotas the hospital sets is the criterion on which they are judged and that physicians are reluctant to speak out on quality issues for fear of retaliation. All in all, this paints a bleak picture of the relations between doctors and management and an equally bleak picture of the care JPS should be providing. How have things come to this?

Cecero: "I can't honestly answer that question, because that's very anecdotal. I will tell you that ... [recently] we had a great medical staff retreat with the medical staff leadership and the administration. We were fortunate enough to have one of our board officers attend as well. And we talked about planning for the future together. So when you say things have come to this, I can't really address someone saying to you, whether it's fact or folly, that they fear from retaliation because we've never retaliated against any physicians."

Throughout the InSight Advantage reports, there were comments that the staff feels their concerns are unheeded, so they don't bother speaking up about them or patient needs. They don't believe that management will address the problems. How does that impact the ability to recruit and retain quality nurses and other staff?

Cecero: "If it's rampant, it's a huge problem. If it's anecdotal, if it's one or two individuals, any time you have an organization of 4,000 people, it's not healthy and it's not positive. But every month we have a meeting, called the CEO and You, and we usually have anywhere from 50 to 100 individuals there. Oftentimes we get great suggestions and we put committees into play. Or we've asked people to take on initiatives."

What are your concerns about copayments? Do you ever have concerns that copays become barriers to your patients?

Cecero: "If they become a financial barrier, we have [a Partners Priorities] program which will help underwrite that. But if at the end of the day, if patient is not able to pay their copay that is a JPS Connection patient, we write it off to charity care."

What has been the long-term strategy to set aside tens of millions of dollars in annual surpluses?

Cecero: "Our board policy is a hundred days' cash on hand. And in round numbers, that's probably close to $200 million. ... In addition to that, we have some restricted funds, which are on the balance sheet."

Interviews were conducted by reporters Anthony Spangler, Darren Barbee and Yamil Berard.

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.

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Series at a glance

Sunday: 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

Today: A Q&A with JPS administrators