A major factor behind Parkland Memorial’s patient care crisis is the hidden power struggle between the hospital and its medical school partner, UT Southwestern Medical Center.
Publicly, Parkland Memorial Hospital and its affiliated medical school, UT Southwestern Medical Center, present a united front. “We have a great relationship,” the hospital’s longtime leader told a group of aspiring UTSW doctors just last fall.
Behind the scenes, however, the reality has been far different. Dr. Ron Anderson, the former CEO, lamented the “vitriol” from UTSW faculty doctors, who supervise patient care at Parkland.
“They honestly don’t know how to work collaboratively with another (non-UTSW) physician who is demanding higher levels of performance and accountability,” he wrote in late 2011.
The tension between the two institutions reflects their tangled relationship. Parkland actually has little control over the doctors working under its own roof. Most are employed by, or answer to, UTSW. Parkland’s priority is supposed to be patient care. Yet UTSW lists its missions as medical education, research and patient care — in that order.
The organizations’ divergent missions, business interests and turf battles contributed to a dysfunctional culture at Parkland over the last decade, jeopardizing patient care, The Dallas Morning News has found.
Federal safety monitors have flagged the culture as a major factor in plunging Dallas County’s hospital for the poor and uninsured into its safety crisis.
Many times over the last decade, UTSW faculty physicians have failed to show up to care for Parkland’s patients. Instead, they see privately insured patients at the medical school’s separate system of hospitals, or focus on research. Resident doctors-in-training at Parkland often have been left with little or no faculty supervision. And front-line caregivers who report to the doctors, especially nurses, have felt powerless to resolve patient-care breakdowns.
Trust and transparency issues abound.
Welcome to the annual UTSW-Parkland cage match,” UTSW’s chief of internal medicine wrote in a September 2010 email to colleagues, describing contract talks with Parkland over the cost and scope of physician services.
“We can’t let them control faculty,” another UTSW chief said in an email to co-workers last March.
The problems between the two institutions run deep. Parkland’s ability to change depends in large part on UTSW. But few, if any, governmental or industry standards exist nationally to help responsibly manage such complex partnerships.
Since 2004, at least three separate consultant firms have urged Parkland, for the sake of better and more efficient patient care, to change its management model to take more control of clinical operations from UTSW. The Dallas County Commissioners Court, which approves Parkland’s budget and appoints its board of managers, also was put on notice. But the contractual relationship between Parkland and UTSW has remained fundamentally unchanged.
“That [relationship] has to be dealt with,” said former Parkland board member Chris Luna, who left in early 2011. “It’s daunting. The culture at Parkland can’t be fixed unless UTSW’s power is addressed.”
The institutions’ problems could worsen after Parkland and UTSW both open new, larger hospitals in the next few years.
Federal regulators and onsite safety monitors have prescribed 499 reforms to turn around Parkland by the end of April. By then the hospital must prove that the changes have taken root or lose massive government subsidies vital to staying open.
Doing that means transforming the culture, according to the monitoring team of Alvarez & Marsal Healthcare Industry Group. The monitors have warned of widespread divisiveness. They have said Parkland workers are lacking in personal accountability and could be desensitized to patients. They have cautioned that UTSW may put the “training and teaching of new doctors above a safe patient experience.”
Recently, the monitors said progress had been made toward a safer culture but warned that a “check-the-box” mentality, instead of sincere efforts at reform, persists. They also wrote of doctors’ lack of engagement in changing their practices, as well as their limited grasp of the government’s action plan for reform issued a year ago this month.
UTSW declined to discuss its relationship with Parkland or furnish details about the work its doctors provide at the hospital. In a statement to The News, it called the model “successful” and stressed the school’s commitment to improving health care through doctor training, biomedical research and patient care.
“UT Southwestern’s partnership with Parkland Hospital is structured to ensure outstanding patient care while fulfilling our responsibility as a state institution to educate and train future generations of physicians to care for the people of this community,” the statement said. “Based on the many hundreds of thousands of patients cared for under this arrangement, we believe the current model has been — and will continue to be — effective in achieving both of these mission-related goals.”
Current Parkland officials also have declined to answer most questions from The News about the alliance, including whether they would pursue a new staffing model.
Since 1943, the public has entrusted the two tax-funded institutions with balancing their different missions.
Parkland furnishes the grounds for UTSW’s doctor training and research pursuits. The medical school serves as the exclusive provider of care for Parkland’s mostly indigent patient population. For those services, UTSW is now paid about $160 million a year.
Their 10-year affiliation agreement, last renewed in 2006, touts the relationship as a national model and a “covenant of mutual responsibility.”
But UTSW’s influence inside Parkland is vast: Its physician force accounts for virtually all of the doctors at the hospital — about 1,000 residents and an estimated 700 faculty members who are supposed to supervise them. Doctors, with a few exceptions, don’t directly report to the hospital’s leadership.
The school has essentially acted as a shadow government over clinical care. Its department chairmen oversee Parkland’s clinical departments. Its faculty physicians serve as the direct chiefs over departments. Its faculty members serve as medical directors over units inside departments.
Parkland directly employs only a handful of attending physicians in its administration or on the main campus. It mainly provides the supporting cast for the UTSW physicians: about 2,500 nurses, hundreds of aides and techs, and directors who supervise them.
The patient safety spotlight has been on Parkland as the entity certified by the U.S. Centers for Medicare & Medicaid Services to receive government funding. But most of the serious patient care breakdowns that forced Parkland into a rare form of federal oversight last year were a shared responsibility with UTSW, which doesn’t answer to CMS.
Dr. Kern Wildenthal, president of UTSW from 1986 to 2008, said the “standard of physician care and supervision by UT Southwestern faculty in Parkland was judged to be high in each and every review by every accreditating agency during my tenure.”
Yet, Alvarez & Marsal outlined more than 50 violations — better than half of all regulations — in the comprehensive analysis of Parkland it completed a year ago. Parkland’s failures in infection control, emergency care, surgical services, resident supervision, physical medicine and rehabilitation, and psychiatric care, among other areas, also fell under UTSW oversight.
“We believe the current operation of Parkland’s resident training program is contributing to the hospital’s deficiencies in meeting all standards,” the monitors said, referring to the program jointly administered with UTSW.
In reality, there are two separate chains of command inside Parkland.
Parkland’s chief medical officer, for example, is supposed to provide leadership over clinical affairs and quality of care at the hospital. Yet the UTSW president “is actively involved in the selection, regular evaluation and decision to continue or terminate the employment of the CMO,” according to the affiliation pact. The current interim chief medical officer is a UTSW faculty member paid by the university, not Parkland.
Employees say the system — what some call the “two-headed beast” — fosters confusion and chaos.
UTSW medical directors, for example, are expected to collaborate with Parkland department directors on decisions. But the structure stymies cooperation.
“Ideally, they’re supposed to meet and discuss the best approach to provide the best of care for patients,” said a former Parkland nurse who has filed a legal claim against the hospital and requested anonymity for fear of retaliation. “What occurs is: they collide. Both have power and both want control.”
UTSW research projects — about 700 studies are currently under way at various stages at Parkland — also can derail patient care priorities.
“If the resident or attending is seeing a patient for medicine management, yet there is also a study on medicine management for which they need participants, during their appointment the resident may cover both,” the nurse said. “This will back up the patient load for the day. The residents get brownie points from their attending [faculty] doctor for signing up participants.”
Parkland’s longtime management structure failed to give the chief nursing officer direct oversight of nurses, despite the title. Many nurses have felt powerless because of the blurred lines of authority. Yet they are expected to backstop and monitor the very doctors who give them orders.
Safety monitors flagged that as a serious problem in their February 2012 report. Nurses, they said, are the “constant eyes and ears of hospital care,” adding that it was crucial to have a vigilant nursing service to monitor the residents.
As part of its reforms, Parkland has now given the chief nursing officer direct authority over the nursing staff.
Concerns about physician oversight kept surfacing over the years as UTSW embarked on an ambitious growth and profit-making strategy, opening its own hospitals.
In late 2000, the school purchased St. Paul Medical Center as a private-referral hospital for its faculty physicians. Five years later, it took formal ownership of Zale-Lipshy Hospital, a private facility adjacent to Parkland that UTSW had managed since 1989.
Some Parkland officials were alarmed.
“Up pops St. Paul, and we’re thinking, it’s a difficult situation for faculty doctors to be covering three different spots,” said a former Parkland board member.
Nurses were regularly noticing that faculty physicians weren’t showing up for work, leaving residents alone to deal with patients. A frequent comment was, “Where’s the doctor?” several caregivers told The News. Parkland employees weren’t always sure whether to take problems up their own chain of command because some of the hospital’s top executives were paid UTSW faculty members.
Anderson, for example, was a tenured professor at UTSW, his alma mater, for most of the 30 years he served as Parkland’s chief executive. He earned $100,000 total in supplemental salary from UTSW until payments stopped in 2007, records show. Parkland officials told The News that board members became concerned that state law prohibited such dual payments, and the practice was halted by UTSW. Parkland’s policy now is that “no one double dips,” according to a hospital statement.
Anderson was forced to resign as Parkland’s CEO more than a year ago after federal inspectors confirmed the hospital’s patient-safety breakdowns, though he was retained as a paid consultant through the end of 2012.
For years, there were concerns that Anderson had conflicting loyalties between the hospital and medical school. After Anderson resigned, a coalition of area churches and schools asked Parkland board members to find a new permanent CEO “free of any conflict of interest.” The group’s leaders, who had worked with Parkland for years on community health care issues, told The News that Anderson’s potential conflicts were behind the request.
Anderson told The News that his role with the school did not compromise his Parkland oversight. As for the payments from UTSW, they were “small” and were reported to the board, he said.
By late 2003, Parkland’s emergency room waits were averaging 13 hours. Women were going through labor in hospital hallways. Packed operating rooms were forcing delays.
Anderson believed a new larger hospital complex was the solution to those problems. So he and the Parkland board moved forward with a $1 billion strategy to build one.
But county commissioners, concerned about the hospital’s ability to manage costs amid government funding cuts, forced Parkland to put the plans on hold. Instead, they hired an outside firm, Health Management Associates, to do a comprehensive study of Parkland.
In 2004, the firm began pointing to the medical school as a major source of problems.
UTSW president Wildenthal was demanding that Parkland increase by $24 million what it paid for annual medical services, saying the school was being underpaid. In Texas, because of a lack of state funding, medical schools generally recover the costs for providing indigent care from the hospitals that contract for their services.
At Parkland, faculty doctors, Wildenthal contended, were working longer hours because of new national accreditation standards that capped residents’ work hours. At the time, Parkland paid UTSW $70 million for its doctors’ services, including supervision of residents and administrative overhead. (Parkland ultimately paid UTSW an additional $7 million for the next fiscal year, which began that fall.)
But the HMA consultants questioned the payments. UTSW had been unable to document much of what it was delivering to Parkland. Administrative costs were “extremely high.” UTSW was charging for “performance enhancements” to encourage more faculty members to supervise care at the hospital — behaviors that consultants said “shouldn’t need additional payments to assure.” And payments to more than 100 medical directors who “had no identified real authority” needed explanation, they said.
They also noted the contract had more than tripled since 1993, when it was $22 million, “despite the lack of any significant service volume increase over the past decade.” They called for more transparency in the partnership and suggested a third party verify costs.
Dr. Allan Shulkin, who served as a Parkland board member between 2004 and 2009, recalls that steps were taken to try to confirm UTSW’s physician costs. But he wasn’t sure how effective they were.
UTSW’s new focus on profits saddened Shulkin, now a pulmonary specialist at Medical City Dallas Hospital and a member of the Texas Medical Board. “You could see that there was another agenda evolving,” he said.
He remembered a different culture during his residency at Parkland in the 1970s.
“We viewed our mission as almost sacred to take care of the poor.”
The consultants also spent months evaluating Parkland’s clinical operations. They found a chaotic and fragmented structure.
UTSW’s academic mission was sidetracking care, they said. Parkland was a “resident-run” hospital.
“The foundation of the clinical care delivered at Parkland is built on the teaching model wherein the training needs of residents essentially guide policy and practice,” the HMA report said.
Trainee-doctors bottlenecked emergency care through unnecessary patient evaluations. Those “who need to experience certain kinds of surgeries in their training, will often look for the most interesting cases, leaving general surgeries behind.” In Parkland clinics, residents ran patient care while a faculty physician “personally never lays eyes or hands on the patient.”
“Most [UTSW] physicians work substantially in other venues and admit [patients] to other hospitals,” consultants said, referring to UTSW facilities.
A common complaint among doctors was that they didn’t know “who is in charge.’’
HMA urged Parkland to work with UTSW toward achieving a dedicated staff, where UTSW physicians — or doctors hired by Parkland — would spend most or all of their time at Parkland. It also urged the hospital to negotiate with UTSW to give the chief medical officer clear authority over the school’s doctors.
But Anderson hesitated.
“Our partnership with the medical school has been a wonderful asset,” he said, adding that he would explore the dedicated staff proposal.
At the time, Parkland’s board was operating without a patient quality committee — a common vehicle used by hospitals across the country to address problems. Such a panel wasn’t activated until after John Dragovits took over as chief financial officer in 2006.
Over the next few years, Anderson’s administration moved aggressively on the new construction front. Parkland hired PricewaterhouseCoopers to work on a strategic plan and master facility plan.
Parkland developed a campaign to replace its old hospital. “We will define the standards of excellence for public academic health systems,” the vision statement said. “The construction of this facility is an opportunity to maintain that vision.”
In 2007, PricewaterhouseCoopers supported plans for a new $1.2 billion hospital. But the firm also echoed some of HMA’s concerns, saying Parkland’s partnership with UTSW created “operational inefficiencies inherent in the teaching process.”
That draft report, obtained by The News, urged Parkland to seek partnerships with other health care services, with or without the support of UTSW, because it had “no substantial provider relationships beyond UT Southwestern.”
It also identified another weakness. It was imperative, the firm said, that Parkland develop quality metrics, as recommended by the national Institute of Medicine, to measure the clinical performance of doctors and to benchmark itself against other hospitals.
Parkland had been paying UTSW without rigorous methods for assessing the quality of doctor care.
By fall 2010, the hospital’s patient-care breakdowns had become widely known. The News had been investigating them since March after a UTSW surgeon alleged that lax resident supervision and absentee doctors were causing widespread harm at Parkland.
One case involved Jessie Mae Ned, a former Parkland employee whose leg was amputated after she was injured during a surgery by a UTSW resident. Following the surgery, Ned went three days without seeing a faculty doctor as she faced life-threatening complications.
Former board member Luna recalled board discussions in 2010 about changing the physician model out of fear that UTSW doctors were spending too much time at their own hospitals and transferring Parkland’s privately insured patients to the school’s hospitals.
“There was this growing concern: Are there two classes of care?” Luna said.
Anderson remained passive, he said. When such changes were discussed, Anderson would say, “It’s not provided for in the contract,” Luna recalled. “He used that a lot.”
Another board member, Alan Walne, once pressed Anderson on that point, Luna said. “We can change the contract. If it’s not right, if it’s not the best thing, we should fix it,” Luna recalled Walne saying. Walne declined to comment for this story.
Dr. Lauren McDonald, who resigned as chairwoman of Parkland’s board last year, said the board instructed Anderson to move toward developing a staff of doctors dedicated to Parkland. “The CEO did not follow through on this along with other important recommendations. You are aware of the outcome,” she told The News.
Anderson said it had been his intent to move toward a dedicated staff, with the help of UTSW. “I wanted to see it happen,” he told The News. “But it will take time to grow into that model.”
He noted that he had persuaded UTSW some time in the few years following the HMA study to agree to allow Parkland to employ and supervise a handful of its own medical directors, as well as have the chief medical officer report to Parkland instead of to both institutions.
In late 2010 a third group of experts, Chartis Management Consultants, issued a striking new finding: Roughly two-thirds of the 700 UTSW doctors assigned to Parkland were spending 50 percent or less of their time at the hospital.
The News obtained only a summary of the report, so it’s unclear whether the consultants offered any more details on the physician absences. Parkland has refused to release a copy of the full report. Chartis did not respond to inquiries.
Like previous consultants, Chartis did not say the Parkland-UTSW alliance is inherently bad. To the contrary, such hospital-school collaborations can be highly effective if both parties work more closely and openly, and ensure “a cadre of faculty physicians whose primary focus is the care of Parkland’s patients,” the firm said.
“Parkland needs a model where most of the care is provided by physicians practicing at Parkland 75 percent or more of their time rather than the current situations,” Chartis said.
Parkland “must be steadfast in its negotiations with UTSW due to the complexity and magnitude of change required,” and it must be prepared to hire its own doctors, the report said.
That fall, Parkland officials sought some changes in the contract with UTSW, though it is unclear whether the request was tied to the Chartis findings. The hospital asked for guarantees from UTSW to commit a group of hospitalists — specialists in acute hospital care — to Parkland 100 percent of the time, according to emails obtained from UTSW through an open-record request. The emails don’t make clear how many doctors would be involved.
Inside UTSW, administrators balked.
“The 100 percent dedicated Parkland hospitalist language is not something we can abide by, it’s not how we are structured, and not something we can be in 100 percent compliance on,” Dr. Ethan Halm, chief of internal medicine, wrote in an email to colleagues. “These are UTSW faculty, not Parkland employees.”
He called the negotiations a yearly “cage match” and insisted that “most of the people who split their time [between hospitals] spend the vast majority of their time at Parkland.”
It’s unclear what happened as a result of the hospitalist negotiations. But over the next two years, both sides continued to battle over staffing, revenue and control. One UTSW official said in an internal email that a “nuclear option” be considered to fire an employee appearing to side with Parkland’s effort to regain some control.
Dr. Claus Roehrborn, chairman of the UTSW urology department, emailed other school leaders in December 2010 expressing frustration over a proposal to provide additional urologists at the hospital. Parkland officials should “find themselves a urologist,” he wrote.
“None of our faculty is truly all that interested in working with a group of nurse practitioners thoroughly disinterested in their job, being reprimanded by the administrators around every turn, and having no patient of their own to follow,” Roehrborn wrote. “Plus, I really need them to all work at Aston [a UTSW ambulatory care center] and Zale. Far better for our enterprise.”
In December 2011, his last month in office, Anderson described “the vitriol of some of our medical colleagues” toward his chief medical officer. The criticism, he wrote in the CMO’s job evaluation, “is directly in proportion to [the CMO’s] pressure for needed change in supervision (amount and quality).” He also said that the current patient safety problems “have to be owned by Parkland, not blamed on UTSW.”
UTSW officials refused to disclose to The News exactly how many of their physicians work at Parkland. After they initially declined to answer a series of questions late last year, they sent a follow-up statement saying they “categorically reject” the findings of the Chartis study and did not have input into them.
In the statement they acknowledged, “While several hundred of our faculty contribute to patient care and teaching at Parkland to some degree, more than two-thirds of care is provided by a much smaller subset (about 30 percent) of our faculty.”
That subset of doctors, they said, is “essentially dedicated to Parkland and do not have appreciable practice responsibilities elsewhere.”
Wildenthal, who left his presidential post in 2008, also said in a statement that “there was a steady, progressive, and dramatic increase in the number of excellent faculty physicians rendering care and supervision at Parkland” over the last two decades. That was made possible, he said, because of the school’s ability to recruit physicians who care for both Parkland patients and UTSW patients.
n the comprehensive report last February in which federal safety monitors detailed Parkland’s many problems, including culture, they stopped short of calling for an end to the UTSW staffing model.
However, in addressing one of the most troubled areas of the hospital, the psychiatric emergency room, they wrote:
“The contractual and financial relationship between Parkland and UTSW cannot be a barrier to the imperative that there must be consistent physician coverage by doctors who are interested and committed to … promoting a new model of care. The Hospital [should] look to non-UTSW physicians for consistent coverage,” if necessary.
Federal regulators also have not directly called for an overhaul of Parkland’s relationship with UTSW. David Wright, deputy regional administrator for CMS, said that fixing Parkland’s most pressing problems — rampant unsafe practices — is the agency’s top priority.
“It’s like trying to walk through a building full of clutter,” Wright said when asked whether CMS or monitors would pursue such an overhaul. “You’ve got to get rid of all the clutter before you can see all the cracks in the foundation.”
Still, federal overseers have been helping Parkland regain control in a variety of ways.
Parkland has persuaded UTSW to commit full-time faculty doctors to the understaffed psych ER, the scene of a series of violent incidents including the death of patient George Cornell following illegal restraints two years ago Sunday. Last week, Parkland struck a deal with a private psychiatric firm to manage all mental-health services.
The hospital has developed a system to document and audit supervision of residents across the hospital but it is still being tested. And, recently, the hospital has contracted with a private company of physician-specialists to staff its urgent care center, which relieves pressure on the main ER.
The hospital also has greater authority over an influential medical executive committee responsible for evaluating doctors and developing proper clinical practices. Committee members were previously appointed by UTSW division chairmen and stacked with faculty doctors who worked primarily at other hospitals. The committee now consists of doctors who work at Parkland.
In addition, Parkland is developing a quality improvement program to measure and monitor patient outcomes and employee performance across the hospital, as required by federal regulations.
Dr. Marty Makary, associate professor of surgery and public health at Johns Hopkins University, said a safety-centered culture is fostered by an administration that measures outcomes, seeks employee input and moves aggressively to fix problems.
“Everyone agrees they know what a healthy culture looks like. But it takes time to change a culture and a business model,” Makary told The News. “In terms of a business model, you can’t fix something if you can’t measure it.”
Health care systems also must be transparent with the public about their breakdowns, said Makary, author of the new book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.
“What you don’t want is a situation where leaks to the press lead to embarrassment,” he said. “That’s a system where there is detached management, and people wait for things to blow up and they do patchwork fixes in response.”
Dr. Laurence McCullough of Baylor College of Medicine in Houston is among the few researchers nationally to study the complex power relationships between hospitals and medical schools. He says there is a need for uniform ethical standards to help oversee the partnerships across the nation. Fostering transparency between such organizations is a crucial element, he said.
Otherwise, the quality of care can be corrupted by other forces, he said.
“You have to be anticipating ethical challenges so you can manage them,” said McCullough, a professor of medicine and medical ethics. “When an organization focuses on the bottom line, it loses sight of care. That’s a formula for trouble.”
What it will take to fix Parkland’s problems, the federal monitors said, is a cultural transformation. Everyone, no matter the job, must be focused first and foremost on patient safety.
In retrospect, Dr. Shulkin said he wishes he and other Parkland board members would have taken stronger actions to protect the hospital’s mostly low-income patients.
“I would blame the skill of the medical school in being able to avoid what we were asking of them, and our not putting them to task for it,” he said. “I would demand a lot more accountability from UTSW. I would demand an investment from UTSW, an emotional investment for responsibility for patient care” at Parkland.
Dallas County Judge Clay Jenkins said Parkland needs to revisit the findings of past consultants calling for improved doctor coverage of patients and more openness.
“Parkland must require that doctors are sufficiently present at the hospital and focused on patient care,” Jenkins said after The News shared its findings with him. All contracts and internal rules “must include improving and maintaining transparent safeguards.”