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Asked if he sensed an ax hanging over his head, Don Smithburg conceded it was possible though he chose not dwell on it—preferring instead just to keep “plowing the hard yards” as CEO of the LSU Health Care Services Division, which oversees the state’s public hospital system.

The news came two days later, late in the afternoon on Friday, June 8: Smithburg was out, reassigned as head of HCSD to work on “special projects” under the direction of outgoing LSU System President Bill Jenkins.

How’s that for timing?

Whatever his faults, Smithburg was likely undone at least in some measure by the management system of which he was a part. His expulsion from HCSD came after a spate of negative publicity for LSU over the way it runs the charity hospital system it took over from state control in 1997.

Was it a sign of tough accountability as LSU System leadership makes the tough choices in dealing with charity care and medical education in the post-Katrina haze? Even Smithburg, who says he’s a big fan of Harry Truman’s “buck stops here” management style, isn’t so sure.

“To me, it’s real unclear where the buck stops,” he said two days before becoming the former HCSD chief. “I can read the legislation, and I can read the bylaws of the Board of Supervisors and LSU. But when it comes to decision-making, it’s hard to know how and where decisions get made ultimately, because there’s so many moving parts.”

Some critics, while praising Smithburg for his accomplishments as hospitals chief, say his ouster—or rather, reassigning—was long overdue. That it didn’t happen sooner, they argue, points to a lack of accountability within a management system that doesn’t have everything it needs to function properly. What’s it missing? A vital component: executive staff with expertise in health care management.

Under the microscope

The problem came into much sharper focus after Hurricane Katrina. Now LSU is hurrying to put that staff in place, albeit belatedly.

“It all boils down to we got to have good info to make good decisions,” says John George, a Shreveport physician appointed to the Board of Supervisors last year.

That Smithburg’s firing didn’t happen sooner also points to weak leadership, critics say. Despite the system’s official line to the contrary, Jenkins—while revered—is by definition a “lame duck.” George doubts anyone in Jenkins’ position—looking forward to retirement after years of laudable service to LSU—would be eagerto chop off heads and make enemies unnecessarily unless forced to by, say, too much bad publicity.

LSU System spokesman Charles Zewe says the lame-duck tag is nonsense, insisting Jenkins is fully engaged.

George, who calls himself a “Smithburg fan,” says that if the former HCSD chief wasn’t working out, he should have been replaced a long time ago rather than just gradually bleeding him of his authority. It’s a case of poor management, George says, adding that in Jenkins’ defense he has no staff—yet—to advise him on what to do.

“If you’re not going to support one of your leaders, get rid of them,” George says.

Smithburg stepped on toes within the system, getting crossways with LSU New Orleans Health Sciences Center Chancellor Larry Hollier, for example.

And the bad press: One glaring issue that still hasn’t been resolved involves six mobile clinics LSU has been trying to get deployed around New Orleans for several months. Though badly needed, the clinics remain parked on University Hospital property in pieces while city of New Orleans and LSU officials snip through miles of red tape with what appears to be a pair of dull nail clippers.

Zewe admits the situation is “inexcusable and intolerable,” and says Jenkins has become involved to get the clinics deployed sooner rather than later. Zewe says LSU probably deserves half the blame. Whatever the case, it looks bad.

Also, the search for land for a new university hospital and trauma center in Baton Rouge has dragged on for some three years now. Meanwhile, Earl K. Long Medical Center, Baton Rouge’s decrepit charity hospital, isn’t improving. In addition to the ever-present specter of having its accreditation yanked, EKL got in trouble with the federal Center for Medicaid Services earlier this month for patient accommodations and sloppy bookkeeping.

EKL got right on the problems and fixed them, as revealed by a surprise CMS follow-up inspection. Still, it looked bad.

The job of finding land for the hospital once belonged to Smithburg, though that authority was taken over by the LSU System office and made the responsibility of Ray Lamonica, the system’s general counsel.

Zewe says LSU can’t be faulted for not pushing hard enough to find a site. Finding property to build a large public hospital, especially in the southern part of East Baton Rouge Parish where there’s already so much growth, is a tall order, he says. Still, a site announcement should be made soon—perhaps within a month, Zewe says.

The final straw for Smithburg, who’d already been informed his contract would not be renewed when it came up in August, might have been his public tiff with University Hospital Administrator Dwayne Thomas over the New Orleans mobile clinic fiasco. It spilled out at an LSU Board of Supervisors meeting in front of reporters and audience members, much to the displeasure of board members.

We’ll never know how things would have gone for Smithburg under a differently structured system. In its present form rivalry is inevitable among the hospitals CEO—formerly Smithburg—and the chancellors of the New Orleans and Shreveport teaching hospitals when they plead their cases before the Board of Supervisors.

“It wasn’t that they were giving false information,” board member and retired Metairie physician Jack Andonie says. “But they each approached it from the standpoint of their institutions, their own point of view.”

Reaching a consensus

With nobody to do it for them, it’s been up to the president and Board of Supervisors to sift through everything thrown at them by two biased chancellors and an equally opinionated CEO and, ideally, come to a consensus that enables them to make a decision that somehow furthers the cause of LSU medicine.

It’s cumbersome—especially since health care management expertise is in short supply around the board table and the LSU System office. Andonie, chairman of the board’s health care work group, for years was the only board member with any medical background.

Being a doctor made him slightly better equipped to make sense of complex issues involving LSU’s $2 billion health care behemoth—10 hospitals, two medical schools, a nursing school, dental school and various allied health programs. Still, the arrangement seemed to work fairly well—at least until Katrina, Andonie says. Then everything became complicated.

In March, following recommendations by Andonie’s work group, the Board of Supervisors created six new executive-level positions—including a vice president of health affairs and medical education reporting—reporting directly to the president and the board. The work group’s suggestions followed a report by the Association of Governing Boards of Universities and Colleges, which recommended similar changes.

Whoever fills those spots will be charged with researching system issues and making recommendations to board members and president, who no longer will have to rely solely on their own limited expertise and sales pitches from medical school chancellors and hospitals CEOs.

LSU is hoping to receive at least $2.5 million from the state budget to pay for the positions, though Andonie says it’s got to be done whether the Legislature comes through or not. It might even take more than $2.5 million, he says, depending on the level of expertise with which LSU winds up. The system office is already looking at résumés, he says.

The effect of not having staff in place is simply that decisions take longer to make, Andonie says. And LSU obviously doesn’t have the luxury of time these days.

“As far as I’m concerned, I’m quite anxious to get these positions filled,” Andonie says. “It is a high priority for us to do this. Some way or another, we’ve got to find the money."

Bob Keaton, special assistant to the system president, says LSU has an amendment for $2.5 million in the Senate Finance Committee.

“We’re really counting on the Senate Finance Committee to give us the money,” he says.

Others wonder why it’s taking so long.

George, the Shreveport doctor appointed to the board last year, says LSU years ago started down the road of bringing in a vice president for health care, though for some reason it never happened. Maybe some board members have been waiting for a new president to replace Jenkins. Even so, George thinks matters are too urgent to put it off any longer.

“I would agree with that under normal circumstances, but these are extraordinary circumstances,” he says. “We’re having a health care crisis.”

George says South Louisiana’s crisis is infecting the northern part of the state, as patients who once would have gone to New Orleans for treatment are forced to travel elsewhere. Shreveport is experiencing a months-long backlog in heart surgeries that it didn’t have before, George says.

“It’s putting a strain on our whole system,” he says. “We have to take action. I think we need to take some chances. If nothing else fill those spots with consultants.”

Smithburg says it makes sense to proceed quickly.

“Because we don’t know when there’s going to be a change in the presidency, there are some things that are pressing enough that there ought to be a way—whether it’s through consultants or something like that—to try to develop that intellect now and help bring together the three disparate parts of the health enterprise toward a common strategy,” he says.

Heaping praise

State Sen. Joe McPherson, a Democrat from Woodworth, says the Board of Supervisors deserves credit for recognizing the need for these executive positions. For one thing, it would allow LSU to monitor its health outcomes and document successes when improvements take place.

Andonie says there was an assumption when LSU took over the state hospital system in 1997 that Merv Trail, the late New Orleans Sciences Center chancellor who almost single-handedly engineered the move, would transfer from the chancellorship into some type of system level executive role—basically what’s in the works today, a decade later.

But then Trail died, leaving nobody to fill his shoes.

“It just sort of went by the wayside,” Andonie says.

Jim Brexler, who was HCSD chief before Smithburg, was personally recruited by Trail. Brexler, who left LSU in 2004 to become the president and CEO of Erlanger Health System in Chattanooga, Tenn., says a deal being cut at the time of Trail’s death included installing Trail in a new executive position reporting to the president and board.

“His ego wouldn’t have allowed him to be vice president,” Brexler quips. “He would have had to be president of something.”

Despite disagreements, there is consensus that things would have been different for LSU health care had Trail—remembered for his charisma and knack for charming the Legislature and inspiring loyalty—lived longer.

For one thing, LSU probably would have had a new hospital in Baton Rouge a long time ago, Zewe says, and mobile clinics probably wouldn’t be mired in the bureaucratic muck of New Orleans.

“I think we would not be having this conversation,” he says. “I think things would be dramatically different.”

Zewe takes issue, meanwhile, with certain pejoratives being flung at LSU lately—words like “leaderless” and “dysfunctional.” He calls it hyperbole.

“Sometimes people get frustrated and strung out,” Zewe says. “Yes, we have problems. Yes, we need these management positions. Trust me, we understand the issues and we’re working the issues as quickly as we can.”

He thinks hiring a health and hospitals vice president will dispel some of the criticism because it will make things more functional and streamline decision-making.

“When you’re dealing with an organization as large as we are—I hate to compare it to a federal government agency, but it’s similar,” Zewe says. “It is a large institution that requires a lot to manage.”

As for Smithburg’s plans, the ex-hospitals chief returned Business Report’s most recent phone call through an employment lawyer with Clouse Dunn Khoshbin in Dallas. The lawyer, Keith Clouse, wouldn’t say much other than Smithburg disagreed with LSU System leadership regarding his reassignment.

Asked if a call from an attorney meant Smithburg planned to try to sue the LSU System, Clouse laughed before mincing words.

“I plan to speak with LSU,” he said.