Provide names of other journalists involved.
Brooks Egerton, Miles Moffeit, Reese Dunklin, Sue Goetinck Ambrose, Ryan McNeill, Daniel Lathrop and Sherry Jacobson
List date(s) this work was published or aired.
Jan. 9, 2011 – Dec. 24, 2011. (More than 50 stories published as part of a rolling investigation, along with numerous DMN Investigates blog posts, 12 editorials and three Ask-the-Editor columns.)
Provide a brief synopsis of the story or stories, including any significant findings.
Our 2011 series revealed systemic problems in care and cases of patient harm, even death, at Parkland Memorial, one of the country’s landmark public hospitals. Parkland and its academic affiliate, the University of Texas Southwestern Medical Center, had allowed doctors in training, and even students, to practice on Dallas’ most vulnerable patients, often with little or no supervision. The consequences of such lapses in care were especially acute and tragic in Parkland’s psychiatric ER. Our reports, including one on the death of a psychiatric patient who was restrained face down on the floor for up to 15 minutes, prompted federal health investigators to launch a hospital-wide inspection. They confirmed our findings and reported additional problems that put Parkland’s patients in “immediate jeopardy.” The hospital lost its Medicare funding qualification, and was allowed to remain open only after accepting a rare form of federal oversight. Parkland is the largest and only the fifth hospital nationwide so sanctioned. The U.S. Justice Department also collected $1.4 million in a Medicare fraud settlement involving Parkland and UT Southwestern over lax supervision, and it launched a broad and ongoing inquiry into other issues. Parkland fired its CEO, increased its nursing staff, and reformed procedures on everything from sanitation to supervision. Its psychiatric emergency room quit paying unlicensed medical students as caregivers — a practice we had revealed — and fired abusive staff members. Two Texas lawmakers began work on legislation to better protect mental-health patients from abuse and death. We also spent six months analyzing hospital patient data from throughout Texas in response to the refusal by Parkland and UTSW to share with us the metrics they claimed would refute our reports. Our analysis of Patient Safety Indicators showed that Parkland had been among the worst five hospitals in Texas for several years. It also allowed us to give readers their first detailed look at patient safety in the state’s hospitals.
Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?
Nearly every story was informed by (if not based on) documents or data we obtained. We submitted more than 100 open-record requests under both federal and state FOIA laws for the personnel files of caregivers, autopsy reports, regulatory inspection reports, police reports, hospital policies, memos and other internal correspondence. We are involved in five open-record lawsuits, some first filed in 2010, to compel Parkland and UTSW to comply with the Texas Public Information Act. We also filed a complaint with the Dallas County district attorney’s office alleging criminal violations of the records law. Parkland has resisted orders from the Texas Attorney General to turn over records to us by suing the agency six times to block release. For our data analysis, we obtained three years of patient-level data from the Texas Department of State Health Services — about 9 million records. These data, known as discharge or administrative data, include a record for any inpatient discharged from virtually any Texas hospital. The data include basic information on demographics and location, as well as all the diagnoses and procedures for each inpatient. We used additional state datasets that contained information about the size and mission of each hospital. We followed a methodology developed for the Agency for Healthcare Research and Quality, a division of the U.S. Department of Health and Human Services, and specifically its Patient Safety Indicators software to track potentially preventable medical complications at Texas hospitals.
Explain types of human sources used.
We cultivated current and former employees of Parkland as sources, ensuring a continuous flow of tips and confidential documents. This was no small feat. Sources told us that employees’ jobs were threatened if they talked to the press, and high-level hospital managers conducted searches for internal leaks of information. In addition, we built relationships with patients and families of deceased victims to compile medical histories and to obtain additional records from Parkland that had been withheld from them. We also mined valuable sources inside federal and state government agencies.
Results:
In general, our coverage prompted reform at a cherished but change-resistant institution and significantly improved patient care for the region’s neediest citizens. Specifically: • In response to our reports, the Centers for Medicare & Medicaid Services conducted a series of inspections of Parkland and verified the problems we uncovered. Inspectors also corroborated our 2010 reports, which Parkland and UTSW had vehemently denied, about inadequate supervision of young doctors in training at the hospital. • After failing the inspections, CMS disqualified Parkland from Medicare funding. Because such a revenue loss would have forced closure of the public hospital, regulators allowed it to continue operating under a rare form of federal oversight, making Parkland the largest hospital in the nation ever to be placed under such supervision. • The U.S. Justice Department recovered $1.4 million in a Medicare fraud settlement involving Parkland and UTSW, based on the same allegations of lax resident supervision we had reported in 2010, and launched a broader and ongoing inquiry that includes Parkland’s psychiatric department, the focus of much of our 2011 coverage. • Parkland replaced its CEO of 29 years and several top managers. The new CEO promised to “be transparent even when it hurts.” The hospital spent millions of dollars to increase its nursing staff and revamped procedures on everything from sanitation to supervision. • The psychiatric unit stopped using unlicensed medical students as paid caregivers and fired abusive aides, some of whom have faced criminal investigation. • As the year came to a close, two veteran lawmakers, citing our coverage, began pushing for tougher laws to protect mental-health patients from abuse and death.
Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.
No organization has requested a correction or clarification. Before publication of the data analysis project, we provided each hospital in the Dallas-Fort Worth area a report card showing how each performed on the Patient Safety Indicators tracked by the software. The Dallas-Fort Worth Hospital Council, an industry trade group, responded that our analysis painted “an incomplete and inaccurate picture” because the data “reflects Medicare cases, patients known to have higher rates of medical complications than the general patient population.” After we pointed out that The News did not use Medicare claims data in its analysis, and that the council uses the very same software and data analyzed by the newspaper for its member hospitals, the group’s president backtracked. “I want to make it clear that we are not questioning or challenging the accuracy of his data,” the council’s president wrote in an email prior to publication. “We have reviewed some of his data and compared to our data and we did not reconcile exactly, but were very close. … At any rate, we do not challenge his numbers.” He attributed the slight discrepancies to differences in publicly available versus internal data, and ultimately said his main opposition was to our publishing the names of hospitals in connection with the data. After publication, Dr. Daniel K. Podolsky, president of UT Southwestern Medical Center, ridiculed the analysis in a letter published on the university’s website. Podolsky said the analysis contained “several critical flaws.” We have attached a point-by-point rebuttal from managing editor George Rodrigue, explaining the flaws in Podolsky’s claims.
Advice to other journalists planning a similar story or project.
Patience and perseverance are critical. Hospitals, particularly teaching facilities and medical schools, are seen as benevolent institutions in their communities, and they often have important connections with decision-makers at all levels. Anticipate blowback. We suggest using open-records laws aggressively to pry loose information from targeted institutions and to seek patient-safety data available through government agencies (see below). Just as crucial is developing relationships with patients and/or their surviving relatives to access medical records in order to document the personal impact and ensure total accuracy. To build trust, it’s important to be sensitive to victims’ concerns, disclose how they will be portrayed and offer them choices, particularly when dealing with mental-health patients who often fear being stigmatized. For the data analysis, we read extensive amounts of medical literature to identify national experts on the subject matter. Our CAR editor flew to California to meet with two leading experts and enlist their guidance on the project. They included Kathryn McDonald, a Stanford University professor who is principal investigator on the federal government’s Quality Indicators program on hospital performance, and Dr. Patrick Romano, a University of California-Davis physician, the program’s clinical lead. Throughout our reporting, their advice and guidance were key to helping us ensure that we understood the limitations of the methodology, the data, and how to present our findings in a fair and accurate way.