Helping Dallas' public hospital survive a near-death experience

When medical malpractice attorney Debbie Dudley Branson was asked to serve on the Board of Managers at Parkland Health & Hospital System in Dallas, she was told the position would require no more than 12 hours a week. But since she accepted the position three years ago, it mushroomed into a 60-hour-a-week job for Branson, who later was elected by her fellow trustees to chair the public hospital system's seven-person board.

She did not foresee the magnitude of the coming crises. Branson became the guiding force leading Dallas County's all-important safety net system through life-or-death challenges. But Parkland emerged on the other side with significantly improved quality of care and a soon-to-be-opened new central facility. For her achievements, Modern Healthcare has selected her as Trustee of the Year for not-for-profit health systems.

Starting in 2008, the safety net hospital—best known for treating the mortally wounded President John F. Kennedy 50 years ago—faced a series of state and federal investigations into its clinical and financial practices. Those probes culminated in 2011 when the CMS, in a rare move, threatened to exclude the hospital from the Medicare and Medicaid programs, putting at risk $450 million a year in payments. The CMS action followed investigative articles in the Dallas Morning News in 2010 alleging severe quality-of-care problems; lack of supervision by attending physicians over residents and medical students; and billing fraud. The newspaper accused the hospital of fiercely resisting the release of information about these issues.

But last August, after more than two years of intensive work by Branson and her fellow leaders, the CMS removed the 769-bed hospital from probation and said it was in substantial compliance with federal conditions of participation. During those years of crisis, Branson and the board were instrumental in replacing Parkland's long-standing and nationally known CEO, Dr. Ron Anderson, and in bringing in interim executives to address the system's wide-ranging quality and safety problems.

After more than two years without a permanent president and CEO, Branson and her colleagues recently announced the appointment of Dr. Fred Cerise, who previously served as secretary of Louisiana's state health department.

“It's vastly different,” Branson, 59, said of Parkland today versus three years ago. “It's cleaner, it's safer, (and) I think the attitude of the tremendous staff we have is better.” The system's working relationship with nearby University of Texas Southwestern Medical Center, which provides most of its physicians, also has improved, she added.

Branson's level of commitment comes as no surprise to her friends and colleagues, who describe her as a natural leader with a tireless work ethic and gift for connecting with people and identifying their strengths. Branson said she is motivated by the opportunity to make a difference. She found that in spades as board chair at the venerable Parkland, which opened its doors in 1894 and came to the brink of being shut down soon after she joined the board.

Parkland, which serves a population of 2.4 million in the Dallas area, faced heavy regulatory scrutiny even before Branson came on. Last year, the hospital announced it would pay $1.42 million and enter into a five-year corporate integrity agreement to resolve a 2010 lawsuit alleging improper Medicare and Medicaid billing.

Parkland's big troubles worried everyone in the Dallas-area healthcare community. As one of the U.S.' largest safety net providers in a state with the nation's highest rate of uninsured residents, the hospital last year treated 213,928 patients in the emergency department and reported more than 43,000 inpatient admissions. It performed more than 25,000 surgeries and delivered 12,391 babies in 2011.

“If anything happened to Parkland, the private and for-profit hospitals would be in trouble,” said board member Jerry Bryant, who worked for 35 years in administration at Dallas-based Baylor Health Care System. He noted that Parkland provides about half the area's indigent care.

There is no question Parkland was in dire condition when Branson arrived. “Rarely has such a large healthcare organization been the subject of such intense regulatory scrutiny, along with management change, as Parkland has been over the last year,” the Alvarez and Marsal Healthcare Industry Group wrote in a 2012 report.

In July 2011, five months after Branson joined, the CMS completed a comprehensive survey of the hospital and concluded that Parkland was not in compliance with one or more conditions of participation that either had caused or could cause serious injury or death to a patient. Subsequently, it was put on notice that if it did not correct its quality and safety issues, it would face loss of reimbursement from Medicare and Medicaid, which could have shut the hospital down.

Complicating matters, the contract for Anderson, Parkland's president and CEO since 1982, expired in August 2011 and the board of managers decided not to renew his contract. The following month, Parkland entered into a systems improvement agreement with the CMS to correct the issues.

Meanwhile, the system had started construction the year before on a $1.3 billion hospital scheduled to open in 2015. So by the fall of 2011, Branson and the board were juggling the huge tasks of addressing the major quality and safety problems while also moving forward to ensure the hospital's future—all without a permanent CEO in place.

Branson said this meant the board needed to install an effective interim team and that the entire system had to apply a sharp focus on the 499 to-do items on the corrective action plan. During that period, she and other board members were at Parkland day and night, said Ron Laxton, who became Parkland's chief implementation officer in March 2012 to work on the systems improvement agreement and is now chief operating officer.

Laxton said Branson, who was first elected to a one-year term as board chairman in March 2012, was unwilling to accept defeat on any quality issue. She also maintained a constant presence with both the hospital's leadership and its clinicians. “She just has that calmness under fire that you have confidence in her leadership skills,” Laxton said.

Parkland used the corrective action plan as an opportunity to implement systems and performance improvements, create changes within the organization, and secure Parkland's future as a leading healthcare institution, Laxton wrote in his letter nominating Branson as a Trustee of the Year. “Her listening skills and ability to ask cut-to-the-chase questions served Parkland well during each phase of the CAP and beyond,” Laxton wrote.

All that work paid off, when the CMS finally determined last summer that Parkland had met the conditions of participation.

But some think Parkland still has more work to do. John Wiley Price, the ranking member of the Dallas County Commissioners Court, which oversees Parkland, remains hesitant to call Parkland a success story. “They are now where they should have been all along,” said Price, who has criticized Branson and the Parkland board for its protracted CEO search process and an alleged lack of transparency. “I have hopes for Parkland. They still have a long ways to go.”

Parkland's finances also remain uncertain though they improved somewhat last year. It reported $767 million in total operating revenue in fiscal 2013, up about 3% from $745.4 million in 2012. Its operating loss decreased 1% to $451.6 million in 2013, compared with $458 million in 2012.

Branson was hesitant to join the board when her friend Clay Jenkins—who as Dallas County judge presides over the county commission—asked her to serve in the appointed position. That's mostly because she already had a full-time job, working with her husband in the Law Offices of Frank Branson, where they mostly represent plaintiffs in medical malpractice cases. An avid reader, she also loves yoga and biking as well as tending her orchids at their second home in Key West, Fla. Every Sunday afternoon, though, is reserved for spending time with her young grandson, Barrett.

A fourth-generation attorney, Branson said her law background has prepared her well for her role at Parkland. “It has been hugely helpful,” she said. “I ask a lot of questions. I have the ability to analyze a lot of information.”

Fellow board member Bryant also said Branson's legal skills and knowledge have been important in the turnaround. Previously Parkland leaders did not have a clear understanding of the laws and regulations governing the hospital. “Debbie brought this perspective of: What is the law? What are the requirements? What must we do to ensure we have processes in place to follow the rules and regulations of the law?” he said.

Branson is quick to thank her fellow board members and interim CEO Bob Smith for their major roles in helping the system turn around. Smith taught her “calm certitude,” she says.

But she has brought many of her own leadership strengths to the role. “She's very appreciative,” said Donna Holmes, Branson's assistant for 22 years. “She tells you exactly what she wants.”

Her ability to express appreciation has gone a long way. During the CMS probationary period, Parkland's nursing staff “was feeling pretty beat up,” Bryant says. He recalls that Branson invited about two dozen nurse leaders from the hospital's different departments to a board meeting so board members could thank them personally and acknowledge their hard work.

Branson expresses confidence in Parkland's future under Fred Cerise's leadership as president and CEO. And construction of the new hospital facility is expected to be completed this summer.

“What was important to me was (finding) somebody who really understands and has a passion for public healthcare, and has a vision and ability to create a strategy to take Parkland to a higher level,” Branson said.

And Branson will stick around to oversee this new and better period of Parkland's history and make sure Cerise's tenure is successful. Last week, the board elected her as chair for the third time.

“I feel like I'm not quite through,” Branson said. “I really want him to have the best chance for success he can have, and I want to make that transition as easy as possible for him.”

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