Sunday, July 29, 2007

There was no indictment

Anna M. Pou, MD was a respected professor with 16 years experience in medical practice when she was arrested last year for the murder of four hospital patients in New Orleans in the aftermath of Hurricane Katrina. Last week (July 24) the Orleans Parish grand jury declined to indict Dr. Pou, and according to the New York Times, the District Attorney of New Orleans “agreed with the grand jury.”

The Attorney General of Louisiana ordered Dr. Pou’s arrest last year (July 18, 2006), along with the arrest of two nurses on second-degree murder charges. The charges against the nurses were subsequently dropped in exchange for their testimony for the prosecution.

The deceased patients were from Lifecare Hospital, which operated an intensive care unit with a separate staff in leased space at Memorial Medical Center, where Dr. Pou practiced. Could ordinary workplace differences have contributed to confusion or misunderstanding or even rivalry that may have affected witnesses' perceptions of Dr. Pou's intentions or actions?

Dr. Pou has not discussed the events in detail because her legal ordeal is not finished. There are several civil suits pending against her.

The American Medical Association said it is “proud of Dr. Pou” and expressed concern that patient care decisions can become criminalized, especially when such decisions may be “made during the chaotic aftermath of a disaster, where medical personnel and supplies are severely compromised.”

I have written before about the difficult heroism of hospital workers in New Orleans in the aftermath of Katrina. The news media was full of photographs, showing dramatic helicopter rescues of stranded individuals, but there were no cameras to record what doctors and nurses and other hospital workers did, under duress, as they continued caring for patients.

The heroism of New Orlean's health care workers in extremis has not been fully appreciated, and the prosecution of Dr. Pou has no doubt tainted the public perception of caregivers. The decision by the grand jury not to indict Dr. Pou is one step to clearing up this matter.

Saturday, July 28, 2007

What’s up with the Berger Commission?

There are two stacks of documents in my office, totaling nearly 21 inches in depth. These are my notes, letters, worksheets, reports, legal memoranda, and state documents, all of which relate to the Berger Commission.

The Berger Commission is the informal name of the Commission on Health Care Facilities in the 21st Century that last year recommended
“Van Duyn Home and Hospital and Community General Hospital’s (CGH’s) Skilled Nursing Facility be joined…under the control of Community General Hospital, and downsize their combined number of RHCF (residential health care facility) beds by approximately 75” (p.103).
I’ve written about the Berger Commission before. See the previous posts: What the Berger Commission said, I wrote about ‘right-sizing’ before the Berger Commission, and Q&A on CGH & Van Duyn.

The Berger Report is more than a recommendation. According to a 2005 state law, the Commission’s recommendations became law on January 1, 2007 because they were not reversed by the State Legislature in the prior year. Therefore, CGH and Onondaga County, Van Duyn’s sponsor, are legally required to comply.

On July 11, 2007 CGH and the County applied for New York State grant funds so we can comply. The state made $550 million in grant funds available this year to help organizations meet the Berger mandates. The Commission itself understood the need for such funds. Writing about CGH and Van Duyn, it said “The reconfiguration and change of ownership…will require capital support” (p. 103).

CGH’s grant application includes planning money, as well as estimated implementation costs. The estimated costs could change as a result of planning yet to be done.

Figuring out how, exactly, to comply with the Berger Commission has not been easy – despite seven months of discussion with the County and despite a number of Albany trips to meet with the New York State Health Department. As a result of these talks, we have identified two possible models for compliance, dubbed scenarios A and B.

Scenario A assumes the intent of the Berger Commission can be achieved by a cooperative planning structure that involves both CGH and Van Duyn without any change in Van Duyn ownership. Scenario B would involve the transfer of Van Duyn to CGH’s corporate structure as the Commission envisioned. The state has not taken a position on either scenario but has stated an interest in seeing the costs associated with both.

The County prefers scenario A. In fact, the County has filed a lawsuit against the state that would block the Berger Commission as it affects Van Duyn. The Civil Service Employees Association (CSEA), one of the unions representing Van Duyn employees, has also filed suit against the state to stop the impact of Berger on Van Duyn. Both lawsuits are pending.

CGH sees advantages and disadvantages in each scenario and believes the preferred plan will emerge as a result of further negotiations involving the County, CGH and the State.

CGH and the County have a long history of cooperation. In fact, the 43 acres on which CGH sits came from the County in a series of land transfers and purchases that go back to the 1950’s. And CGH’s discussions with the County have been positive and cooperative throughout this process.

We both agree that making either scenario work will require state funds. And whichever scenario is decided upon – or perhaps another scenario entirely – will require adequate time to plan and to implement.

The Berger Commission had a vision for the future of CGH and Van Duyn. “An integrated organization,” it wrote, “will reduce the duplication of services across the two facilities, reduce operating costs at Van Duyn, enable Van Duyn to receive a hospital-based reimbursement rate, and create an integrated continuum of care on the campus" (p. 102).

What are the prospects of receiving grant funds necessary to achieve this vision? It’s hard to say. According to a July 18, 2007 state news release, more than 60 hospitals and nursing homes have applied for the $550 million in available funds.

Stay tuned.

Friday, July 27, 2007

More on bugs

My recent post on the importance of hand washing in hospitals was timely. See the story in today's New York Times: "Swabs in Hand, Hospital Cuts Deadly Infections." Two notable quotes from the story:
  • "...a relentless focus on hygiene...can reduce the number of dangerous infections."
  • "'That I lost my mother to someone not washing their hands or cleaning a hospital room properly is disgusting to me.'"
You can find the full report at:

Saturday, July 21, 2007

Where's Sue?

This week we saw a Sue Chamberlain who is, shall we say, two dimensional.

As the Infection Control Program Director at Community General Hospital, Sue is ubiquitous, showing up in the early morning hours, on evenings, and during weekends in the ICU, on the med-surg floors, and in the lab. She is, as we know, a coach, an educator, a friend, and always our conscience in a white coat.

Now she is also a stand-up sign that points at staff and visitors alike to ask, “Did you wash your hands?”

As I’ve previously reported, Community’s ongoing monitoring shows a 95% compliance rate with hand washing protocols, significantly greater than the national average, to be sure – but what about the remaining 5%?

Sue’s stand-up sign is a friendly reminder that washing hands is one of the most important things we do to reduce the risk of infection.

I introduced the cutout at a management meeting Wednesday morning and afterward placed it in the main lobby. By the next morning, one good humored soul, who will be nameless, had left a whimsical message with the sign: “Have you seen this lady,” it read. “Missing since 7/19/07. Seen last by the Purell® dispenser…”

Expect Sue, either the stand-up sign or the genuine article, to appear soon in a location near you. As a sign, she serves as a reminder. As herself, she continues as resource, educator, and conscience.

Let’s achieve and maintain 100% hand hygiene compliance at Community General Hospital.

Saturday, July 14, 2007

What teammates do

In the early hours yesterday, a nurse in the emergency department praised a resident physician who, after a busy night, was still at the desk writing orders for patients. “He’s been just terrific,” the nurse said of the resident. “We’ve been swamped. There were 15 admissions overnight, and he never complained. He just did what was necessary for the patients.”

It’s a small thing, acknowledging a good play by a colleague. Or is it?

You find plenty of “attaboy” moments in professional baseball. When the Los Angeles Dodgers beat the San Francisco Giants, 9-1, yesterday, the Dodgers lined up on the field to congratulate one another. There’s a photo on today’s major league baseball website, showing Luis Gonzalez high-fiving teammate Andre Ethier after the win.

As second baseman Brandon Phillips touched home plate yesterday, his Cincinnati Reds’ teammates Ken Griffey Jr., Ryan Freel,[1] and Adam Dunn were there to celebrate his grand slam at Shea Stadium. The Reds went on to beat the Mets, 8-4.

Some baseball players make minor rituals of their celebrations with choreographed series of slaps, waves, and fists. But players support their teammates with more than congratulations. They offer consolations too when performances are less than stellar.

Everyone has a bad day now and then, and athletes know it’s important to keep up their teammates’ spirits for the next time they take the field. The players are saying, in effect, “You’re good. Don’t worry. You’ll do better tomorrow.”
At yesterday’s Texas Ranger game, catcher Gerald Laird consoled pitcher Joaquin Benoit with a gentle fist to the stomach as Benoit prepared to leave the game in the ninth inning. The Los Angeles Angels beat the Rangers, 2-1.

How do we support our teammates? Do we high-five their achievements? Do we encourage them when they’re down?

A patient was promptly transported to the floor? “Way to go!”

A nurse took the time to show kindness to a confused or angry patient? “That was very nice of you.”

The environmental services staff responded appropriately to a spill? “Very good. Thanks!”

The room set-up took too long in the OR? “Hey, we’ll do better next time!”

Peer congratulations and encouragements are hardly unique to baseball players. They are the daily life of all athletes, amateur and professional. And they should be part of our daily life in health care too.

[1] Ryan Freel played for the Syracuse Chiefs in the years 1998-2001.

Sunday, July 8, 2007

How to be an expert

“If you’re the first one in (to work) in the morning and the last one to leave (work) at night and you take fewer vacation days and never take a sick day, you will do better than the people who don’t do that. It is very simple.”[1]
That’s the advice New York City’s Mayor Bloomberg gave recently to college graduates. I had similar advice for my sons when they were growing up. The parental lecture went something like this:

Let’s say the recipe for success in life is equal parts intelligence, good luck, and hard work. Native intelligence and good luck are out of our control, but we can control how hard we work. Working hard tips the odds in our favor, giving us a better-than-average chance of success.

Now comes an article in the Harvard Business Review that says expertise in our chosen fields has less to do with IQ than it does with practice-makes-perfect. The writers report that research shows “there is no correlation between IQ and expert performance in fields such as chess, music, sports, and medicine…”[2] They give us the recipe for becoming experts:

  • Start early,

  • Practice a lot (for at least ten years); and

  • Find good mentors along the way, preferably unsentimental ones who give us honest feedback

Years of doing something does not necessarily make us expert at it. Experience alone is not sufficient. Performance improves to expert status only by “deliberate practice.” Deliberate practice means the concentrated rehearsal of skills that we cannot do well. One example from the article is that of a novice golfer who, in a relatively short amount of time (perhaps 50 hours), learns to play a reasonable game. Without deliberate practice, however, that golfer, even after decades of social games, will not significantly improve.

With deliberate practice we improve the skills we already have, plus we work on new skills, especially those outside our comfort level. “Moving outside your traditional comfort zone of achievement,” the authors report “requires substantial motivation and sacrifice.”[3]

Even if we don’t have a teacher or coach, the article suggests we can learn from people in the work place who are more expert by closely observing what they do – and then by deliberately practicing on our own the skills we’ve observed in others.

I do think there’s something to Mayor Bloomberg’s advice. The person who takes his job seriously and devotes time to it will succeed. But continuous learning – deliberate practice – helps make one a true expert in one’s field. Significantly, practice, like hard work, is something we control. It is not dependent on others or on lucky breaks. Becoming an expert requires only confidence in ourselves, some self-discipline, and perseverance.

[1] Michael Bloomberg’s address to graduates at of City University of New York’s College of Staten Island, May 31 2007, as quoted in “Bloomberg’s Roadmap to Success,” the Wall Street Journal Washington Wire, June 20, 2007. See:
[2] Ericsson, et. al., “The Making of an Expert,” Harvard Business Review, July-August 2007, p. 116.
[3] Ericsson, et. al., p. 119.