Building a Better Parkland

In recent years, Parkland Memorial Hospital in Dallas, Texas has faced intense media scrutiny and government investigations into patient safety lapses. As the hospital searches for a new CEO, the Dallas Morning News asked me and other experts to answer the question: “What kind of leader does Parkland need to emerge as a stronger public hospital?” Below is the column, re-used with the newspaper’s permission. While it is focused on one hospital, the themes apply broadly. The type of leader that I describe is needed throughout health care.

Public hospitals such as Parkland are a public trust, serving the community’s health needs by providing safe and effective care to a population that lacks alternatives.

Major shortcomings in the quality of care provided at Parkland have eroded that trust. Now trust must be restored. The community is counting on it. It’s literally a matter of life and death.

Parkland’s board is searching for a new CEO to lead this journey. The CEO’s task will not be easy: Resources are tight, resident supervision is insufficient, staff morale is low, systems need updating, and preventable harm is far too common.

History may provide some guidance. Historian Rufus Fears notes that great leaders – leaders who changed the world – have four attributes: a bedrock of values, a clear moral compass, a compelling vision and the ability to inspire others to make the vision happen. Parkland needs one of these great leaders.

The key values of the next CEO should be humility, courage and love — and these values must guide the leader’s behavior. Parkland will not be able to improve unless it acknowledges its shortcomings; this will take humility. Yet Parkland is a great organization with a rich past and bright future. The leader must honor the past and look forward. The leader must be able to live with the paradox of being humble yet confident.

The leader will need courage. Author C.S. Lewis once said that “courage is not simply one of the virtues but the form of every virtue at the testing point.” The Parkland CEO will be at the testing point many times every day. The leader must be unwavering in the goal to improve care yet humble enough to invite all staff to come together to realize the goal. The leader will need to make tough decisions about where to deploy scarce resources, always keeping patients as the North Star.

To avoid a revolt and get staff passionate about the vision, the leader will need to transparently communicate where Parkland is going and why, how Parkland makes decisions and what those decisions are. Yet the next CEO will need to deftly dance between democracy and autocracy, between conversations and results. To make all the needed fixes, to bring Parkland back to where it needs to be, much needs to be done, and only with a passionate and engaged staff can real change happen.

Yet perhaps the greatest value will be love. Avedis Donabedian, one of the fathers of quality improvement, was interviewed on his death bed by a student. The student asked, “Now that you have been a patient and devoted your life to improving care, what is the secret of improving quality?” Donabedian told him, “The secret of quality is love. If you love your God, if you love yourself, if you love your patients, you can work backwards to change the system.”

This is what Parkland needs. The hospital’s doctors, nurses and administrators care deeply about patients; they do not want to harm them. They work with broken, underresourced systems. The next CEO must recognize this and seek to understand rather than judge, to learn and improve rather than blame and shame.

This won’t be easy. The public wants accountability. Parkland is under scrutiny from federal and state regulators. Yet real improvements will come from internal rather than external motivation.

The CEO will need to help the staff see shortcomings in safety as their problem and believe they are capable of solving it. The CEO will need to inspire with lofty oratory, and then drop down, roll up her sleeves, and get things done.

Parkland’s next CEO needs to tap the immense wisdom within the staff by soliciting broad input and inviting hospitalwide brainstorming. The title of CEO still allows the new leader to convene meetings. But true authority comes from trust. Change of this magnitude only progresses at the speed of trust, and trust is based on being perceived as caring and competent. Both are essential. Only through caring and competence can Parkland win back the faith of the community it serves.

Director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Peter Pronovost, MD, PhD is a practicing anesthesiologist and critical care physician who is dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts will appear occasionally on THCB and on his own blog, Points from Pronovost.

9 replies »

  1. Parkland’s problem is that they are always dishonest and secretive with anything that threatens their interests. Their enforced “code of silence” remind me of what the mafia does about all the criminal activities they try to get away with.

    Until that culture is broken, they will never a legitimate medical institution. No CEO can help that God-forsaken institution. As soon as their federally-mandated safety monitors are gone, they will go back to “business as usual.”

    That’s because they place their own self-interests above the health and well-being of their patients. You can see all their short-coming documented on the watchdog website, “The Parkland House of Horrors” at http://parklandhouseofhorrors.blogspot.com.

  2. I am a front line worker at Parkland. Dr. Pronovost, you are correct. Most meetings with managers or administrative staff are one way. Them to us. There is a lot of talking, not much listening.
    I also agree with Jamie, as long as the board members are ‘in bed’ with the county commissioners, they’ll be marginal at best although Debbie Branson seems to be involved and in touch.
    What needs to change at Parkland? 1. Different mindset. No more of the ‘that’s the way we do it at Parkland” New thinking outside the box. 2. New building. Crowded. Crowded. Little ORs, Pregnant women are always laboring in hallways. I think the job we do is remarkable considering what we are given and the limitations. 3. Oversight by CMS. Yes, it’s been stressful being under the microscope but change has happened and everyone’s feet is to the fire. The biggest problem from this scrutiny is no one wants to admit mistakes because YOU’LL BE FIRED. That is one extremely negative side effect from CMS oversight. 4. Parkland’s relationship with UTSW needs to change. Way too much influence at Parkland. Their goal (resident education) is not Parkland’s. Parkland needs to start hiring their own physicians, not just using a staffing service. The physicians needs to be loyal and invested in PARKLAND, not UTSW.
    That’s my lowly 2 cents. The new CEO? Come spend some time with me at my job.
    Not my real name by the way. Probably get me fired for commenting.

  3. The best CEO in the world can’t do it without a good board. The Parkland governance model is deeply flawed and effective governance is sacrificed at the alter of county politics. I fear that must change first ( but won’t) to enable a super-CEO to work the needed magic Peter so eloquently writes of.

  4. In reading this, it’s not clear to me whether Parkland’s issues relate to leadership and culture or to grossly inadequate resources. Do other public hospitals that serve a largely low income population, including many without health insurance at all, perform better with comparable resources per licensed bed or not? If they do, what are the key differences in leadership and culture?

    If you pull a school superintendent and a teaching staff out of a wealthy, high achieving suburban school district and insert them into a poorly funded inner city school with lots of students from broken or dysfunctional families, it’s highly unlikely that the new staff will achieve results anywhere near as good as in the school they came from.

    As Warren Buffett has often said (paraphrasing), if you take a business leader with a reputation for brilliance and put him in charge of a business with a reputation for bad economics, it’s likely to be the business that emerges with its reputation intact. Maybe Parkland is a (healthcare) business with bad economics.

  5. Are there other examples of well run public hospitals to be used as examples? How do they translate their financial constraints and individual care givers’ commitment to the patients to provide quality care?

  6. I visited Parkland two years ago and had never been in such a busy hospital. And it wasn’t just tourists visiting JFK’s OR. Patients were wall-to-wall. The pharmacy had a line like the DMV. Half the place was under construction with tarps and scaffolding. Many of the patients looked like undocumented workers. There were also inmates walking around in stripes.
    I was told that particularly in Texas public hospitals play a major role since the rate of uninsured is high–and the public programs are fairly stingy.
    Anyway–reading this brought back memories of the most chaotic hospital I’ve ever toured. I hope they are able to fix it and add capacity. Clearly a well-run public hospital is desperately needed in Dallas.

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