In January, doctors at one JPS Health Network clinic were buzzing about a consultant’s review showing failings that could threaten the health and safety of patients at the network’s hospital.
Dr. Wayne G. Williams, who was new to the JPS board of managers, heard the murmuring but said he didn’t think to press inquiries. And administrators had never told the 11-member board that they had commissioned the studies, much less presented findings, though the reports cost in excess of $650,000. “I’m at some fault for that,” Williams said, explaining that he should have followed up. Other board members, he said, also believe they should have been asking questions.
Now, leaders on the board and the Commissioners Court, which appoints board members, are examining whether oversight policies were broken or need to be strengthened. Also at issue: What needs to happen when such lapses occur?
Experts say the issues are deeper. The lack of public disclosure reflects an oversight failure by both the hospital board and county commissioners, said experienced members of other hospital boards. Board members aren’t off the hook just because JPS administrators didn’t tell them of the InSight Advantage studies, experts say.
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Recent revelations about the taxpayer-financed health system call into question whether the appointed board has the qualifications and muscle to provide crucial oversight. Experts were particularly perplexed by policies that allowed JPS administrators to make key decisions — such as spending large amounts of money and handling patient safety issues — without board knowledge.
“If I’m spending that much money, I’d like to know what’s it for and where it’s going,” said Dr. Lauren McDonald, chairwoman of Parkland Hospital & Health System. “I have to be able to stand in front of any one resident and anyone in front of the Dallas County Commissioners Court and justify it.“We are ultimately responsible to the taxpayers of Dallas County.”
Some Tarrant County commissioners predicted sweeping changes ahead. The departure of Chief Executive David Cecero gives the commissioners an opportunity to tighten controls and expand their authority. Cecero, hired in 2001, announced earlier this month that he will retire and become an adviser to the board Oct. 1.
Commissioner Marti VanRavenswaay is among those banging the gong for more open communication from JPS administrators. She said she’s never been so blindsided in her 18 years as county commissioner.
“I feel very disappointed in a number of people that I had a great deal of respect for,” VanRavenswaay said. “I feel betrayed. ... Our trust [in hospital officials] is breached. It’s going to take so much to restore that trust.”
The InSight Advantage studies, conducted in 2007 and reported to JPS administrators by late January of this year, found conditions that could put patients at risk, along with troubling indications that an overwhelmed staff had given up on management and grown callous to patient needs.
Some of the concerns raise questions about whether the hospital is meeting standards for Medicare and for accreditation under the Joint Commission, which evaluates healthcare organizations and programs.
For example, the reports spoke of missing medical records — a safety issue — and records stored in the lobby of a clinic, a violation of privacy rules. Consultants also reported that crucial lab results were not reaching physicians for days; some patients with infectious diseases were not isolated; nurses had to leave surgery to find instruments that doctors needed; and bone fragments and blood globules were found in operating rooms that nurses thought had been cleaned.
Those are issues that would concern the Joint Commission, said Dr. Joel I. Shalowitz, director of the Health Industry Management Program at the Kellogg School of Management at Northwestern University in Evanston, Ill.
The Joint Commission, Shalowitz also stressed, would frown on the fact that the hospital board was not involved in the reports.
“This is a major departure from Joint Commission philosophy, which stresses board involvement in oversight,” Shalowitz said.
JPS board Vice Chairman Dan Serna says the board is now trying to determine where it dropped the ball.So far, various explanations have come up. The board might have learned about the reports if it had required administrators to get approval before making any outside expenditure over a set amount. Serna said he believed there was such a policy but wasn’t sure.
One board member, Dr. Gary Floyd, said the InSight reports are an example of the administration’s failure to discuss key issues with the board. “I guess there are some answers that need to be forthcoming as to why it was opted to keep us out of the loop,” Floyd said.
He also said that the board at times is presented with inconsistent data.
“There is no reason that we shouldn’t be looking at the numbers everybody else is,” he said. “I long for the day that we are completely transparent.”
Williams said administrators bury the board in reports that don’t appear to be meaningful. But he said he and other board members have not been able to obtain accurate numbers about patients on the hospital’s discount program or patients seen by JPS doctors.
“Today I called them and asked them about that same thing,” he said Friday. “They’ve been working on that.”
Board Chairman Steve Montgomery also said he was concerned that the board was not receiving adequate information. But he said he wasn’t sure that the InSight studies should have been provided to the board.
“I don’t need to know there is a report that says this, necessarily,” he said in an April interview. “I need to know what resources, as a board member, do I need to give this management to go fix that. But I do need to rely on them to alert me to that.”
Other board members wouldn’t comment or did not return phone calls.
“I don’t think I have anything that I’d like to share,” board member Don O’Neal said.
“I have nothing to say to the Star-Telegram,” board member Martha Walker said and hung up.
JPS does have a policy that allows the CEO or his or her designee to approve contracts worth up to $500,000 without board approval, according to a document JPS provided in response to a Public Information Act request from the Star-Telegram. The policy also states that approval from county commissioners is not needed.
That limit sends a signal on the type of communication the board requires from management, Shalowitz said. By setting the limit high, that gives management “a lot of leeway in what it does, for good or bad.”
Controls are tighter at Dallas County’s public healthcare system.
If the Parkland CEO, Dr. Ron Anderson, wants a consultant report that costs $100,000, his seven-member board lets him do it, said McDonald, the Parkland chairwoman. But if the study costs $200,000 or more, she said, the board is all over it. And the county commissioners have to see it, she said.
“We started this practice five or six years ago for added oversight,” McDonald said.
Even if JPS had tighter controls, the InSight reports still could have fallen through the cracks because administrators awarded the work in a series.
In early April, Chief Financial Officer Gale Pileggi told the Star-Telegram that she had asked for the evaluation to gauge hospital efficiencies and ordered it in increments.
Dividing the study into phases, some say, was a way of preventing exposure to the board.
“If it’d been a great report, I bet the board would have seen it,” County Judge Glen Whitley said. Even if such a report were inexpensive, experts say, administrators are still obligated to share critical findings with their boards.
“When there are widespread quality and safety issues throughout the organization, that needs to go to the board, which needs to hold management accountable for changes,” said Shalowitz, an internist who served on a hospital board for seven years and headed a subcommittee on quality and compliance.
“Something this big must go to the board,” he said. “The fact that it was kept from them is highly irregular.”
Debate on qualifications
Some board members and elected officials say that the JPS board has a long way to go to strengthen oversight. One step: considering board member qualifications.
Montgomery said that, with the exception of the three physicians, “we are community people.” Its members include ministers and a public relations expert. That makes it so “we really have to entrust and put our confidence in our administration,” he said.
But McDonald said that the day of the “coffee and doughnut political boards” is gone. Boards are becoming increasingly specialized and call for members who have knowledge of the healthcare business and law.
“You have to bring something to the table,” she said.
Why does a hospital board need expertise?
Without proper scrutiny of information, the board and elected county officials can’t serve their stewardship duty, which puts taxpayers and patients at risk. What’s more, by law the officials are “fiduciaries” and can face sanctions such as fines and even confiscation of personal assets.
That’s why McDonald says she wants transparency.
These days, if key information is not disclosed or reviewed on some boards, “you could go to jail,” McDonald said. “You work with federal rules that govern Medicare. You make a large mistake, and you may be criminally liable.”
Good oversight boards also establish scorecards to measure a hospital’s quality of care, financial performance and charity outreach, Shalowitz said. For example, at each meeting the board could get metrics on emergency room waiting times, an issue at JPS. To look at financial performance, it can study payer mixes and bad debt.
Charity care can be gauged by enrollment in discount programs and participation in outreach efforts.
With scorecards, the board can evaluate how well administrators are meeting the hospital’s mission, Shalowitz said.
A board also can include specific language in employment contracts that require top officials to report findings of important evaluations. Administrators can also be required to flag information that relates to life-threatening issues, safety and patient care.
“The challenge of the board is to get this information filtered up to us,” Montgomery said.
With such contracts and policies, the board has a remedy when it is left in the dark.
“If they are working with people who aren’t going to be forthcoming, they [the administrators] don’t need to be in that position,” McDonald said.
Staff writer Anthony Spangler contributed to this report.
Yamil Berard, email@example.com