Parkland Hospital Improving, but ED Deficiencies Persist

Parkland Health and Hospital System has made "measureable progress" in its effort to address serious quality and safety concerns, according to a report from its independent safety consultant. Still, the beleaguered hospital failed to meet the target completion dates for some tasks associated with resolving deficiencies in the ED and the psychiatric emergency department.

And the report warns that other "significant tasks and milestones may not be on schedule for timely completion."

The April 10 progress report is the first in a series of required monthly updates that will be submitted to the Centers for Medicare & Medicaid Services by Alvarez & Marsal Health Industry Group, a Washington D.C.-based management consulting firm that specializes in performance improvement.

The 61-page report has just been released by CMS as part of a freedom of information request by HealthLeaders Media. The report itemizes about 400 tasks and action items, as well as completion dates, from the safety net hospital’s corrective action plan. The CAP was approved by CMS in February, but has not been publically released.

While the accomplishments are important, the ED tasks behind schedule are central to the deficiencies identified during a July 2011 on-site review of Parkland by CMS. Those findings set into motion events that led to Parkland and CMS signing a rare systems improvement agreement and the hiring of A&M.

Specifically, Parkland has not yet implemented 100% concurrent case management of all ED admissions and consistent attending psychiatric physician coverage in the psychiatric ED.

Construction halted
Perhaps more troubling is a recent media report that ED screening problems could persist in the new $1.2 billion Parkland Memorial currently under construction. Federal regulators have halted work on the ED facility pending the correction of a design that would have resulted in patients being routed out of the ED to other areas of the new hospital without being screened for their medical conditions.

In an e-mail statement, Lou Saksen, senior vice president of construction, provided no timetable for the redesign stating only that "design changes to the emergency department are under way. Once design is completed, construction to that area will resume in an effort to complete the project on time." The new hospital is slated for completion in 2015.

Regarding other significant delays, the report says some delays are the result of the "need to acquire outside consulting assistance on some of the action plan items. Redoubled efforts and focus will be required in the month of April and May to ensure that these items are completed under the timetables required by the CAP." The tasks include:

• Completing a plan to obtain and guarantee consistent psychiatric physician coverage in psychiatric ED
• Recruitment of permanent nurse managers for the psychiatric ED and inpatient psychiatric unit.
• Implementation of expanded ongoing professional practice evaluation for all medical staff members
• Implementation of revisions and improvements to physician (attending and resident) call and attribution systems
• Implementation of a new and improved technology platform to document resident physician competencies.
• Changes to nursing competencies, tracking of competencies and new competency training procedures may be delayed due to the need to implement a new information technology platform to track the competencies.
• Implementation of the reorganization/restructuring of the care management department and related services (case management, discharge planning, social worker services, utilization management/review) may be delayed given the time necessary to contract with outside consulting firm to assist with reorganization.
• Contracting with an outside consulting firm to assist in HR efforts under the CAP.

Among the key activities cited as completed in the progress report:

• Restructuring of the nursing department, which came under scorching criticism in the 300-page gap analysis report prepared by A&M. The hospital’s interim CEO, Thomas Royer, told HealthLeaders Media that about "75% of Parkland's problems involve inconsistent nursing practices across the system."
• Creating detailed work plans for meeting the CAP requirements. Six workstream teams—governance, clinical operations, access and throughput, nursing, physicians and quality assessment/performance improvement—have completed this task.
• Hiring of a chief implementation officer to oversee the implementation of the CAP. Ron Laxton reports directly to Parkland’s board of managers.
• Hiring a governance consultant, Thomas O’Neil of The Saranac Group, to conduct a board effectiveness review and education program.
• Hiring a search firm to fill the newly created post of chief patient rights and public safety officer. This senior level executive will report directly to the Parkland board.
• Creation of a metrics management work group to capture the more than 100 metrics required b y the CAP.

Efforts to reach Debbie Branson, chair of the board of managers, were unsuccessful Thursday. But she released an e-mail statement highlighting the hospital’s CAP accomplishments to date and reaffirming the hospital’s commitment to resolving its problems.

"We know we still have a lot of work to do to improve this healthcare system that is so important to our community," she wrote, "But everyone from the board room to the emergency department is committed to improving patient safety and quality of care."