Editor’s note: This is the third story in a series on hospital safety. Read the first here and the second here. Subsequent stories will explore the safety grades for specific hospitals in Fort Worth.

The banner unfurled from the garage on Morphy Street in Fort Worth. Employees from John Peter Smith Hospital, across the way, gathered below. 

There were speeches, confetti — a moment of togetherness in November 2021, between the delta and omicron COVID-19 variants, for the county hospital to celebrate the achievement of a long-awaited goal: An “A” safety grade from The Leapfrog Group, a nonprofit that scores general hospitals nationwide on patient safety.

“It’s been a lot to get to an A,” said Dr. Rob Stephenson, a surgeon and chief quality officer at the hospital. “So it was quite cathartic last fall when we got to celebrate that, especially since we’d been cooped up (by COVID-19).”

By early May, when The Leapfrog Group released its newest report, which included some pandemic-era data for the first time, the hospital had dropped back to a B. Still, he said, the grades reflect a renewed focus on patient safety after a slate of C’s from previous seasons.

“That’s the nature of work in quality and patient safety. It’s constant vigilance, constant. If you avert your gaze for just a half second, you go in the wrong direction,” he said. “There’s no ‘fix done.’”

‘Seek joy’ and patient safety indicators

The Leapfrog Group released its first hospital safety grades in 2012. Initially, John Peter Smith Hospital earned a D. A low score is common for public hospitals, Stephenson said. This spring, for example, Parkland Health & Hospital System in Dallas scored a D. So did Ben Taub Hospital in Houston. 

Improvements in patient safety grew over time and out of a cultural shift encouraged by former President and CEO Robert Earley, said Dr. Alan Podawiltz, a psychiatrist with JPS Health Network. Podawiltz chairs the hospital’s patient safety council, a group that manages patient safety data and investigates medical errors. 

After Earley formally took the helm in 2009, he championed three rules: Own it, seek joy and don’t be a jerk. The relationality of those rules began to seep into patient care, Podawiltz said. 

“With JPS, what people did was begin to say, ‘Wait, no, this is my family. And we’re here to care for your family and the community,’” he said. “And once that occurs, then you begin to take a look at, how do we do things better?”

As the years passed, the hospital formalized its focus on patient safety. That meant rethinking organizational structures, Podawiltz said. For example, two groups within the hospital used to co-exist without much interaction: the patient safety council and the quality committee. They met separately and reported data to hospital leadership separately. 

In the mid-2010s, he estimates, the two decided to partner. Now, they meet together and report together. The collaboration allows for more efficiency in addressing safety issues that arise, he said. 

Around the same time, the hospital garnered recognition for its efforts to improve safety outcomes for high-risk patients. In 2014, the hospital launched a trauma care program for its elderly patients. The program works to ensure patients spend as little time in the hospital — before or after surgery — as possible. Shorter stays can prevent muscle atrophy, bed sores, blood clots and depression.

Then, in 2017, John Peter Smith Hospital became the first public hospital in the U.S. to earn the U.S. Joint Commission certificate for sepsis treatment. Sepsis is the body’s “extreme response” to an infection and can lead to organ failure and death, according to the U.S. Centers for Disease Control and Prevention. 

And, in late 2018, the hospital committed to an organizationwide focus on patient safety indicators, Stephenson said. Patient safety indicators are metrics created by the Agency for Healthcare Research and Quality to track preventable harm like infections and bed sores. Texas law requires hospitals to report dozens of patient safety indicators to the state health department. 

Stephenson became chief quality officer in 2019. In late 2018, though, he was vice chief of surgery for quality, safety and patient experience — a role he still holds. About 1 in 4 of the adverse events that Texas hospitals must report relate to surgery. “I saw it as part of my role to figure out how to, No. 1, tune the machine,” he said. 

Under his guidance, the hospital organized a multidisciplinary group of employees to focus on decreasing blood clots after surgery. Specifically, the group designed a customized bundle of medications based on each patient’s risk after surgery.

When a physician assesses a patient, the hospital’s electronic medical record gives the patient a risk score and, depending on the score, orders a specific set of medications designed to prevent blood clots in that patient.

After the group implemented its design in the hospital’s electronic medical record, the improvements were “really dramatic,” Stephenson said. The success was informative; he realized that, with tweaks here and there, the hospital could improve safety outcomes across the board. 

The Leapfrog Group outlines best practices for each metric it spotlights. For example, for blood clots, the website mentions that physicians in “safer hospitals” give patients compression devices and blood thinners to help prevent clots, along with helping patients get out of bed to walk as soon as possible after surgery. 

Following The Leapfrog Group’s recommendations is good for patients, he said: “And so we tightened up our work around some of those things.”

Although he quickly noticed improvements in safety, the scores took time to reflect those changes. 

Because The Leapfrog Group calculates safety grades with hospital data submitted to the U.S. Centers for Medicare and Medicaid Services, the grades reflect at least a year’s time gap

For example, this spring’s grade includes data from a reporting period that began in late 2018, along with some data from late 2020 and early 2021. For Stephenson, this lag explains the continued C’s between early 2019 and early 2021, when the hospital earned a B.

‘A really, really tough situation for a human body’

The A grade didn’t last. This spring, John Peter Smith Hospital earned, once again, a B. 

The drop came from the crush of COVID-19 patients the hospital experienced in the first year of the pandemic, Stephenson said. Behind Texas Health Harris Methodist Hospital Fort Worth, John Peter Smith Hospital had the second highest weekly averages among Fort Worth’s hospitals for confirmed COVID-19 patients in 2020 and 2021. The spring 2022 hospital safety grades include data from that period. 

As in hospitals across the country, COVID-19 patients at John Peter Smith Hospital began contracting central line-associated bloodstream infections and pressure injuries in the first year of the pandemic, Stephenson said.

A central line, or tiny tube inserted into a patient’s vein to deliver medicine, can become infected if germs also enter the bloodstream. Pressure injuries, or bed sores, occur when a body part experiences restricted blood flow from excessive pressure in one spot. Eventually, the skin starts to die. The spring safety grade includes data for pandemic-era central line infections but not pressure injuries.

The uptick in these injuries came, he said, from the positioning of the sickest COVID-19 patients. They were “proned and paralyzed” — face down in the hospital bed, affixed to a ventilator. “That’s a really, really tough situation for a human body,” he said. Many of those patients died, he said, and their deaths took a toll on the staff.

But, he said, humans are “amazingly resilient.” Some semblance of normalcy has returned to JPS. As for the patient safety grade, he’s keeping his eye on it. 

“We all know that we have good days at work and bad days. But patient safety is one of those things where you have to perform at that highest level every single day to make sure that everybody stays safe,” he said. “It’s just what’s required.”

Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.

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Alexis Allison covers health for the Fort Worth Report. When she can, she'll slip in an illustration or two. Allison is a former high school English teacher and hopes her journalism is likewise educational....