Over the past three months, at least 75 employees at Parkland Health and Hospital System in Dallas have been among staff "encouraged to leave" in a widespread shakeup as hospital officials try to improve the much maligned hospital system, HealthLeaders Media has learned.
Interim CEO Thomas Royer, MD, in recent interview, said the hospital is "holding people accountable" and its actions were related to "people (who) have been careless" or "not performing their roles."
"In about 14 weeks, we have seen changes in staffing, numbering about 75 people," Royer says, referring to Parkland personnel. "I'm not telling you that all have been encouraged to leave. I would say a number of them were encouraged to leave." Hospital officials believed that the employees did not meet the administration's expectations for their jobs. "We were setting for their roles they did not have the energy to do, they did not or want to put forth that much effort," Royer says. "(We) decided this was no longer the place for them to work."
While Royer would not discuss specific personnel moves, he did say that most of the issues related to an overhaul at Parkland relate to its nursing programs and the psychiatric unit, the target of many complaints and sharp government criticism. "I would say 70% had to do with consistency and standardization of nursing practice, probably 15% had to do with physicians issues that include documentation, timing of verbal orders, and discharge planning that physicians are involved in," he says.
"We turned over a lot of positions in the psychiatric and emergency departments where this all started a year and a half ago that had to do with consistency of performance and had to do with management and oversight and so forth," he said.
Royer said the moves have been made as the safety-net system works toward compliance for an estimated $417 million in annual Medicare and Medicaid contracts. CMS ordered a review in July 2011 of the entire hospital facility after identifying dozens of deficiencies deemed so serious as to create an immediate and serious threat to patient health and safety.
In September, Parkland and the Dallas office of the Centers for Medicare & Medicaid Services signed a systems improvement agreement, which requires Parkland to be compliant with all CMS rules and regulations by April 2013.
The hospital system hired Alvarez & Marsal Healthcare Industry Group to guide it through the SIA process. A 300-page gap analysis report prepared by A&M detailed ongoing deficiencies, including systemic issues in the role and organization structure of nursing and nursing practices. Royer has said that about 75% of Parkland's problems involve inconsistent nursing practices across the system.
Among the nursing-related deficiency episodes identified by A&M:
- A patient death from respiratory arrest appeared to be related to the administration of a narcotic drug by a nurse who didn't possess either a written or verbal order from a physician for administration of the medication.
- In a one-week period five babies in the nursery received vaccine inoculations and had adverse reactions. Although nursing contacted the hospital pharmacy, neither nursing nor pharmacy completed a patient safety network report for any of the incidents. As a result multiple babies were affected and potentially suffered respiratory distress.
- Nursing staff could not locate or identify on computer the discharge planning screen and stated that they do not commonly refer patients to discharge planning. Parkland's case management department reported that referrals from nursing based on the initial nursing assessment were infrequent.
- An intake nurse in the emergency department placed in an open waiting room a patient reporting suicidal thoughts. The patient wasn't escorted immediately for care or provided a one-to-one sitter until care was available. The patient waited about 30 minutes and then disappeared. Following an intensive search and dispatch by the Parkland Police Department, the patient was recovered at home.
- An ED intake nurse failed to notice a mother and young child and mother on the floor under a water fountain in the ED waiting area. The intake nurse was unaware of the mother or child's presence or status in the waiting area and in fact was reading homework materials when interviewed by an A&M surveyor.
To deal with nursing issues, Parkland hired in January a new chief nursing officer, to deal with "consistency and predictability of nursing in a systematic way," Royer says. Mary K. Eagen was formerly a regional chief nurse executive at Christus Health Southeast Texas in Beaumont. Royer says he wants to see more empowerment for nurses and more team building among the nurses, lead physicians, department chairs, and administrators.
Royer has said that hospital officials have been working closely with A&M to focus on an array of improvements. Key changes include the nursing reorganization, the use of a mock survey team to monitor the implementation of all improvement plans, and enhanced leadership oversight to assure sustainability of the plans.
He also instituted a daily huddle of the management team to review events of the past 24 hours to make sure that necessary corrective actions are taken, that the right policies are in place and that the staff is abiding by the policies.
"We are doing an accountability track," Royer says. "I think there have been days, and episodes, where people have been careless or not performing their roles according to their licensure. We have a policy in place and you do what you need to do based on licensing. We are holding people accountable and making sure our disciplinary action is applied uniformly across the system."
Referring to physicians, Royer says, "I don't think any physicians [have] left. Some of the positions are in peer review," he says. "To physicians, it's the message we are giving everyone. We have four focused goals, the important one is the CMS survey and making sure (doctors) include documentation and stressing the importance that we are in this together."
"We have to be accountable as a team, and that means we need to be honest and open with each other, to say where it is working and where it is not working and try to encourage people what they might do better."
Royer did not indicate whether there will be more personnel moves, but insists that hospital officials want to make permanent improvements "to help assure positive, sustainable change that will improve our safety, quality of care and patient experience at Parkland, he said.
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