Even as the federal government prepares to cut off funding to Baylor St. Luke’s Medical Center’s poorly performing heart transplant program, the Houston hospital has continued to promote itself as a national leader in cardiac surgery.

But the declines at St. Luke’s have not been limited to transplants, a continuing investigation by the Houston Chronicle and ProPublica has found.

In January, a leading group of surgeons rated St. Luke’s as among the worst-performing hospitals in the nation for coronary artery bypass surgery, the most common open-heart operation and a key indicator of a cardiac program’s overall quality.

Four months later, the hospital’s most-experienced bypass surgeon retired — the latest in a series of major physician departures in recent years.

Now, following news reports highlighting the plight of St. Luke’s patients who died after heart transplants, family members of those who fared poorly after bypass operations are second-guessing their decision to seek care at a hospital regarded as one of the nation’s best for heart surgery.

Hospital officials acknowledge the poor bypass rating but say they have improved over the past year. Others, however, say publicly available statistics give reason for concern.

“They need to get better,” said Dr. Ashish Jha, the director of Harvard’s Global Health Institute and an expert in hospital quality measures, after reviewing St. Luke’s bypass outcome data and other measures that suggest care at the hospital has lagged in recent years.

Of nearly 600 hospitals that voluntarily report surgical outcomes to the Society of Thoracic Surgeons, St. Luke’s was one of 18 nationally to earn only one star for overall bypass quality, the group’s lowest rating.

Between the middle of 2016 and the middle of 2017, 19.3 percent of the 494 patients who underwent bypass operations at St. Luke’s suffered major complications, including strokes, kidney failure, prolonged time on a ventilator and infections, according to the society’s analysis, which is adjusted to ensure hospitals are not penalized for treating sicker patients. That’s compared to a national rate of 11.3 percent.

Among hospitals that performed at least 200 bypass operations, none recorded a higher rate of major complications than St. Luke’s. The hospital also scored poorly — toward the bottom nationally — in the percentage of patients who received all of the recommended medications before and after bypass surgery, though the hospital contends the low rating was largely due to a recordkeeping deficiency that has since been corrected.

“There are specific things that the cardiac surgery program could be doing better but clearly is not,” said Jha, referring to the results from mid-2016 to mid-2017. He called STS the “gold standard” for analyzing heart surgery outcomes.

Dr. David Berger, senior vice president and chief operating officer for Baylor St. Luke’s, said changes have already been made. He shared data with reporters showing that the hospital’s bypass performance improved in the final six months of 2017 and will no longer be ranked among the worst in the nation when the Society of Thoracic Surgeons releases updated data later this month.

In an interview Thursday, Berger said the hospital has consistently performed well in what he maintained is the most important measure of a program’s quality: the percentage of patients who are discharged from the hospital and survive at least 30 days after bypass surgery. At St. Luke’s, 98 percent of patients survived at least a month after having a bypass in 2017, better than the national average of 97.5 percent, according to data provided by the hospital.

Berger also shared figures showing the hospital’s major complication rate following bypass operations had improved somewhat in the final six months of 2017. However, the program’s performance on this measure still ranked as one star out of three, statistically below that of other programs.

“We agree that during that time period [mid-2016 to mid-2017] for the cardiac bypass program, we were in certain areas not operating to our potential,” Berger said. “Currently we are providing safe and high-quality care, and we are continuing to improve our performance daily.”

Patients have long come to Houston from across the country for treatment at a hospital known for its affiliation with the Texas Heart Institute, the research nonprofit led by pioneering surgeon Denton Cooley until his death in 2016. In the 1960s and ‘70s, Cooley and his team turned St. Luke’s into one of the busiest cardiac hospitals in the country, refining many of the surgical techniques in use today. That included coronary bypass, in which surgeons use vein grafts to create new routes around narrowed and blocked arteries, restoring sufficient blood flow to a patient’s heart muscle.

That history gave Lisa Blackmon-Jones comfort when her 73-year-old father checked into the hospital in need of a triple bypass in February. Blackmon-Jones, a nurse, had trained at St. Luke’s in the 1980s and remembered scrubbing in with Cooley.

“I was excited to take my dad to St. Luke’s,” Blackmon-Jones said. “I thought, ‘Oh, yeah, they’ll take care of him.’”

Her father, Purnell Blackmon, a former Houston Metro bus driver, was discharged from the hospital without major complications after his surgery — a successful outcome in the Society of Thoracic Surgeons’ scoring system — but he suffered numerous setbacks in the weeks that followed. He returned to St. Luke’s multiple times with a high fever, low blood pressure, a severe infection and anemia, Blackmon-Jones said.

He died at the hospital on April 25 after several days connected to a ventilator.

“That’s not at all what we expected when we took him there,” said Blackmon-Jones, who complained about the quality of nursing care, poor communication from doctors and dirty hospital rooms.

“This was St. Luke’s,” she said. “I thought they were supposed to be the best.”

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The hospital’s poor bypass rating came at the same time federal regulators were scrutinizing St. Luke’s for worse-than-expected heart transplant outcomes.

In July, the Centers for Medicare and Medicaid Services formally notified the hospital it was cutting off funding to its heart transplant program on Aug. 17 because it had not done enough to correct problems that could endanger patients. The decision followed an investigation by the Chronicle and ProPublica that found an outsized number of St. Luke’s patients died or suffered unusual complications after receiving new hearts.

There have been other indicators that St. Luke’s performance has fallen short of its reputation in recent years.

Healthgrades, a company that rates hospitals based on federal data, reported in May that between 2014 and 2016, St. Luke’s performed worse than expected in nine of 13 critical safety measures, including the rates of patients who emerged from surgery suffering from bloodstream infections, excessive bruising, a collapsed lung or respiratory failure. It also reported that a higher-than-average percentage of St. Luke’s patients suffered complications after procedures to implant pacemakers and defibrillators.

On the federal government’s hospital quality website, St. Luke’s is rated below average, two out of five stars. And in a survey of patients posted on the site, patients expressed misgivings about certain aspects of the care they received. Only 59 percent of St. Luke’s patients reported that their room was always clean, compared to 75 percent nationally. Similarly, just 60 percent of St. Luke’s patients said they always received help as soon as they wanted it, 10 percentage points below the national average.

And in February, in a Harris County Medical Society survey of more than 2,000 doctors at 26 Houston-area hospitals, local physicians ranked St. Luke’s at or near the bottom in virtually every category, including overall satisfaction, nursing staff levels, the quality of medical supplies and administrators’ commitment to patient safety.

These declines came after St. Luke’s was purchased in 2013 by Catholic Health Initiatives, a Denver-based nonprofit chain burdened with billions of dollars in debt, and after the hospital entered into a joint-operating agreement in 2014 with its affiliate Baylor College of Medicine. Together, St. Luke’s and Baylor are working to build a new medical campus, including a $916.8 million, 650-bed hospital to replace its aging facility in the Texas Medical Center.

Berger acknowledged that the hospital has lagged in various quality measures, but he said those were all based on “historical” data and do not reflect changes made by a new group of hospital leaders. He provided data from Premier Inc., a company hired by hospitals to track performance measures, showing a steady rise in quality and safety scores since the fall of 2016, when Gay Nord took over as St. Luke’s president.

Since then, Berger said administrators have invested additional resources in the hospital’s quality department, strengthened its physician-leadership structure and worked with doctors and nurses to find ways to improve outcomes. These changes will be reflected once publicly available data catches up to the hospital’s current performance, Berger said.

“The issues that you’re bringing to light focus on a period of time in the institution when there were some challenges,” Berger said. “But I think our current data, which shows really excellent outcomes both from patient safety and from quality, would show that those issues are no longer pertinent. … Those are historical issues.”

Berger acknowledged, and experts agree, that many factors beyond what happens in the operating room can contribute to below-average surgical outcomes. Poor nursing care, post-operative treatment, infection control and prescription drug management can drag down a hospital’s numbers.

Several top physicians left St. Luke’s in recent years after raising concerns about the overall direction of the hospital, which has lost hundreds of employees to layoffs and attrition, some of them in nursing and medical support positions.

Two months ago, the hospital’s most senior cardiac surgeon, Dr. David Ott, turned in a three-sentence note announcing his retirement after 50 years at the Texas Medical Center, according to a copy of the letter obtained by reporters.

More than a dozen surgeons perform heart bypasses at St. Luke’s, but the note marked the end of an era. Ott, who replaced Cooley as the Texas Heart Institute’s chief surgeon four years ago, has long been known as one of the nation’s most experienced coronary bypass surgeons.

Ott’s resignation came the same day the Chronicle and ProPublica published their first story about problems plaguing the heart transplant program, though there’s been no indication that this factored in his decision. In his letter, Ott said he was retiring before undergoing shoulder surgery.

“While much has changed in the medical center,” Ott wrote in the letter, “it remains true that caring for one’s fellow man is one of the world’s highest callings and something in which we can all take considerable pride.”

Berger said the hospital had anticipated Ott’s resignation due to health problems and said he remains confident in the cardiac surgeons who perform bypass surgeries at the hospital.

“We’ve recruited really outstanding cardiac surgeons during the period of time when Dr. Ott was winding down,” Berger said.

Ott did not reply to messages seeking comment for this story.

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Ernest Barnard, a 75-year-old resident of Cypress, a suburb northwest of Houston, checked into Baylor St. Luke’s in the summer of 2016, feeling lethargic and struggling to catch his breath, according to his family. After three weeks at the hospital, family members said the medical team concluded Barnard needed a quadruple bypass to improve blood flow to his heart. The evening before surgery, his children brought him a treat, hoping to lift his spirits.

“I’m a daddy’s girl,” Graciella Gonzalez said. “He asked for an ice cream … so I went to the gift shop and got him an ice cream. And that was his last meal he ever had.”

For nearly two years, Gonzalez and her family have wondered went wrong. They kept friends and family members updated with regular Facebook posts during Barnard’s two-month hospital stay, chronicling his slow decline in real time.

After the initial bypass surgery on July 22, the surgeon told the family he had bypassed only three of four arteries, because the fourth had been too narrow, Gonzalez said. Otherwise, everything had gone well, she and other family members remembered the surgeon saying.

Barnard never fully recovered.

Barnard’s family said they complained to the hospital multiple times about the quality and availability of nursing care, echoing the concerns of several other patients, nurses and other medical professionals interviewed by the Chronicle and ProPublica. They began taking pictures of what they saw and contemplated transferring him to another hospital.

“You’d call the nurse on the phone, and it rings them, but then you wouldn’t see them for hours and hours, so you’d have to call again,” Gonzalez said.

On Aug. 12, three weeks after the initial surgery, a surgeon reopened Barnard’s chest after doctors noticed fluid leaking from his incision. They were worried it might be infected, Gonzalez said. After the surgery, she said doctors told the family there was no infection, which was a relief. They also told the family that the wiring holding Barnard’s chest closed appeared to have come loose at some point after the initial surgery and had been fixed, Gonzalez said.

The next time Gonzalez saw Barnard, she said he had a vacant look in his eyes, and she knew something was wrong. Days passed, but he did not wake up. Later, a brain scan revealed Barnard had limited brain function, Gonzalez said. He didn’t regain consciousness.

A week later, his family made the decision to withdraw life support.

Nobody explained what went wrong, Gonzalez said. She and her family had serious concerns about the care her father received, but until they were contacted by reporters last month, they were unaware of the hospital’s higher-than-average rate of complications following bypass surgeries during the time her father was a patient there.

Family members said they filled out a form more than a year ago to obtain Barnard’s medical records and have followed up several times, but as of Friday, they still have yet to receive them. A hospital spokeswoman said St. Luke’s has no record of the request.

Reporters presented St. Luke’s officials with a consent forms signed by Barnard’s widow, Noemi, authorizing the hospital to release medical records to journalists and freeing staff to answer questions about Barnard’s care. As of Friday, they had not done so. Instead, the hospital issued a general statement on patient care:

“Our goal every day is to ensure that each patient receives the care he or she needs — with compassion and reverence — and goes home as healthy as possible. Our hearts and prayers are with each family when this doesn’t happen, and we are saddened by the passing of any patient while under our care.”

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Poor performance in St. Luke’s bypass program wasn’t a one-time blip. Bypass outcomes began to slide in 2013, the same year the hospital was purchased by Catholic Health Initiatives, according to an analysis by MPIRICA Health Analytics, a company based in Washington state that grades hospitals and surgeons based on federal billing data.

MPIRICA looked at how Medicare patients fared after bypass surgery, taking into account more than 500 possible risk factors. It looked at outcomes 90 days after patients were discharged, compared to 30 days after surgery for the Society of Thoracic Surgeons.

In MPIRICA’s credit score-like rating system, excellent outcomes are considered anything between 600 and 800, fair outcomes fall between 400 and 600, and anything lower is considered below average. In 2015 — the most recent year analyzed — the company rated St. Luke’s bypass outcomes at around 300, the lowest of any hospital in Houston. A few other St. Luke’s surgical programs received low marks in the analysis, while some were rated as excellent.

St. Luke’s officials called the company’s analysis “incomplete” and “potentially misleading” because it focused only on Medicare patients and was based on publicly available billing data, rather than more granular information logged in confidential medical records.

MPIRICA defended its analysis, saying researchers commonly use Medicare data to assess hospital outcomes. Shakil Haroon, the company’s co-founder and CEO, said hospitals spend a lot of time and money marketing their reputations; his company digs into the data to determine if those reputations are justified.

“It is extremely unlikely that what was observed at St. Luke’s is an aberration,” Haroon said.

Larry “L.T.” Thomas, 46, of Lake Charles, Louisiana, was among those who received a bypass at St. Luke’s in 2015, the most recent year for which MPIRICA has released data. He died four months after surgery. Two years later, Thomas’ surviving family members filed a lawsuit against the hospital in Harris County District Court, alleging that doctors and nurses made a series of mistakes during and after his surgery, resulting in major complications.

According to the lawsuit and an expert opinion filed with the court, Thomas, a diabetic, suffered a spike in glucose levels in his blood during the surgery, prompting an anesthesiologist to give two doses of insulin to bring his blood sugar back within a safe range. This common intervention during surgery requires that a patient’s glucose level be measured frequently afterward, according to the lawsuit, but St. Luke’s staff failed to do that.

Dr. Duane Funk, a Canadian anesthesiologist, reviewed the case on behalf of the plaintiffs. His report, filed with the court last fall, said the initial dose of insulin given to Thomas during surgery was too large; the second came too soon. After surgery, Funk wrote, medical records indicated that physicians failed to to make staff in the intensive care unit aware of the insulin treatment. As a result, nursing staff did not check Thomas’ glucose level until it became critically low and he began to have seizures, Funk wrote.

Thomas suffered irreversible brain damage and never left the hospital, according to the lawsuit.

Tim Riley, a Houston lawyer representing Thomas’ surviving family members, declined to comment on the lawsuit, which is ongoing. Lawyers representing St. Luke’s have denied any wrongdoing in court filings and have sought to have Funk’s written testimony dismissed, arguing that he failed to articulate a clear breach in the standard of care provided to Thomas.

St. Luke’s officials did not answer questions from reporters about the case.

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Lisa Blackmon-Jones can’t point to anything specific that led to her father’s death following bypass surgery earlier this year, but like other families, she was disappointed with the care provided by St. Luke’s.

Doctors performed the triple bypass in February, and initially, Blackmon seemed to be doing well, his daughter said. The 73-year-old was discharged from the hospital in under two weeks, giving him hope he would soon regain enough strength to return to his daily routine of swimming laps with his daughter at the YMCA pool near his home in southeast Houston.

But within a month, Blackmon was feeling worse than he did before the surgery, said his wife, Georgia Blackmon. He couldn’t walk from the couch to the kitchen without growing winded; he needed a wheelchair to check the mail.

Blackmon returned to St. Luke’s multiple times in the weeks that followed, his wife said, and doctors ran a series of tests to try to figure out what was causing his low-blood pressure and anemia. They gave him antibiotics, believing he was suffering from an infection, according to family, but the drugs didn’t seem to help.

Blackmon’s condition worsened dramatically during his final hospital stay in April, his family said. One day, family members said they found him gasping for air. His daughter-in-law — another nurse — told staff to get a doctor, family members said, and Blackmon was rushed to an intensive care unit and connected to a ventilator.

Within days, family members said, Blackmon was suffering from kidney failure, his blood pressure was critically low and doctors had begun discussing plans for hospice.

Georgia Blackmon signed a form allowing the hospital to share her husband’s records and discuss his case with reporters. St. Luke’s officials did not do so, instead referring to their general statement about the hospital’s commitment to patient care.

Blackmon died on April 25. A few weeks later, his daughter read news stories about troubles plaguing the heart transplant program at St. Luke’s and reached out to reporters.

“After everything,” she said, “nobody could ever tell us what went wrong.”