More discussion on SEIU

Paul Levy referenced my recent post about the SEIU corporate campaign in his blog, Running a Hospital. Paul is the CEO of Beth Israel Deaconess Medical Center.

Paul's posting elicited some lively follow-up comments, including one that seemed to compare picketing my house to put pressure on contract negotiations at a nursing home with the civil rights protests of the 1960's! Another comment on Paul's blog said, "The hubris is takes to compare any modern day union...to civil rights workers...is staggering." After reading the comments on Paul's blog, I added my own:

Captains-of-industry imagery and class-stereotypes are powerful tools for motivating and for bullying, and the SEIU is masterful at using these tools. Employing the signs and symbols of civil protest, however, does not automatically confer legitimacy on one’s point-of-view or actions.

The SEIU is an organization, like any other. It has no special status as somehow “more moral” or “more politically legitimate.” Because it alleges something does not make it true.

In the days since the SEIU picketed at my home, numerous SEIU members have told me they disapproved of the activity. Some have apologized. They have usually done so after briefly looking over a shoulder so as not to be overhead.

One local labor leader called me last weekend to express personal support and to take issue with the SEIU’s tactics. Significantly, this leader said he was not comfortable expressing such an opinion publicly.

To read Paul's post and the comments it prompted, go to Corporate Campaign in Upstate New York. See also the comments on my initial post, as well.

Wrong-side surgery

Today’s newspaper carries a story about a wrong-side surgery at St. Joseph’s Hospital Health Center. My thoughts go first to the patient – and then to the caregivers at St. Joe’s.

The story recalls a wrong-side surgery that took place at CGH in 2004, about which I wrote last year. I learned about our medical error the morning it happened, and we conducted a root cause analysis that same day. I promptly apologized to the patient for our medical error, and I apologized to the surgeon because our safety processes did not prevent the error.

Hospitals are complex places where modern medicine allows us to do much good for patients, but modern medicine is accompanied by risk. All hospitals rely upon internal processes to reduce the risk of error, but we didn’t follow our process – we failed our patient and we failed each other – one day in 2004.

Following the root cause analysis, we took many other actions to improve our safety processes. We reached out to another hospital administrator who had experienced a wrong-side surgery; she helped us learn from that experience. We invited the Joint Commission to conduct an on-site review, we visited a local company to learn about industrial safety processes, we hired an operating room consultant to help us improve, and we made changes in our Universal Protocol. We re-trained all staff, and each member of the Medical Staff committed to following the Universal Protocol.

Because health care involves human beings, mistakes, regrettably, are possible – not just in the Operating Room, but anywhere. That’s why standardized processes help fallible individuals safeguard patients .

Today's news story reminds us that the lessons from our own wrong-side surgery must remain fresh for all of us.

This posting appeared in a different form on December 16, 2007.

SEIU's corporate campaign

Yesterday members of SEIU 1199 picketed my home. Interestingly, the picketing was not intended to influence me at Community General Hospital, where I am CEO. Instead, SEIU seeks to use me to pressure one of Community’s employees who serves on the Board of Iroquois Nursing Home. I have declined to apply the pressure.

Earlier this year SEIU conducted an organizing campaign at Iroquois. Having won its election on March 7, 2008, SEIU is negotiating its first contract – a process that is not apparently proceeding to its liking, judging by the calls and personal visits I have received from Al Davidoff, SEIU Vice President.

SEIU has made Iroquois the object of a “corporate campaign” intended to pressure, to intimidate, and to publicly embarrass the organization. As a tactic, corporate campaigns have been used by SEIU with organizations across the country, including such notables as Beth Israel Deaconess Medical Center, Sutter Health Care, and even the California Nurses Association. Anyone interested in learning more about this tactic need only search the Internet for “SEIU corporate campaign” and read the links that appear.

Corporate campaigns employ the methods of community organizing, political action, and public relations, such as letter writing, telephone calls, picketing, and publicity. SEIU corporate campaigns target elected officials, as well as candidates for office, and they involve outside organizations in an effort to bring additional pressure on the Board and management of a target organization – in this case, Iroquois Nursing Home.

Along with St. Joseph’s Hospital Health Center and Crouse Hospital, Community General Hospital shares the responsibility to appoint Board members to Iroquois. We three hospitals established Iroquois to meet a community need some 15 years ago, under the auspices of Plaza Corporation, Inc. Plaza is the sole member of Iroquois Nursing Home and Rosewood Heights Nursing Home. Plaza's two nursing homes are independent, not-for-profit corporations, separately licensed by New York State, each with its own Board of Directors.

As the three members of Plaza, Crouse, St. Joseph’s, and Community have the responsibility to appoint qualified community representatives to the boards of both Iroquois and Rosewood. Community’s appointees to Iroquois have served as Directors there from four to 15 years each.

Board members have the legal responsibility for nursing home governance. They are fiduciaries – that means, the Directors have legal responsibilities to the residents of the nursing home and to the communities served by the nursing homes.

About a year ago, the Iroquois Board elected one of the Community-appointed Directors as it chairperson. SEIU thinks that makes Community responsible for decisions made by the Iroquois Board. Mr. Davidoff has asked me to intervene with the Community employee serving as Board chairperson. The intention is to bring pressure from Community General Hospital's management upon a hospital employee who has fiduciary responsibilities at Iroquois.

I have explained to Mr. Davidoff – as I did to his predecessor, Marshal Blake – that Community sees Board membership at Iroquois as a community service, not as a puppet of Community’s administration.

Mr. Davidoff has informed me that SEIU would seek to generate unfavorable publicity for Community General Hospital, unless I make an effort to interfere with the Board of an independent, not-for-profit facility. That apparently is the price one pays for doing the right thing in the face of an SEIU corporate campaign.

We remember September 11

A hospital's characters and its stagecraft

It is commonplace to see the drama of the medical profession portrayed in the popular media. But Hospital, a new book by Julie Salamon, is remarkable for the way it captures the life of a hospital in all its confusing, infuriating and inspiring complexity.

For one year Ms. Salamon had virtually unlimited access to Maimonides Medical Center in Brooklyn, NY – its people and its facilities, day and night. Pam Brier, the President and CEO of Maimonides, knew Ms. Salamon was an experienced writer, the author of other books, whose journalism credits include the New York Times and Wall Street Journal. Nonetheless, it took courage for Pam to give a reporter carte blanche at her hospital.

Pam Brier ends up as one of the characters in Hospital. We see Pam on stage, and we sense her presence even off stage. She addresses the men in a mosque to discuss Maimonides’ cancer center. We see Pam in day and night staff meetings as she demands spending cuts. One night she rounds in the emergency department. We overhear her fretting about patient volume. One manager sulks, thinking he’s been ignored by Pam. A doctor thinks she plays favorites.

I serve with Pam Brier on the Board of the New York eHealth Collaborative, but I do not know her well. I was fascinated to see her, through Julie Salamon’s eyes: someone with personal courage, a bit eccentric, plenty of worries, fully engaged in the life of her hospital and its difficult relationships.

But Hospital is not just Pam Brier's story. There are 69 other characters in the book – doctors, nurses, residents, patients, social and community workers, environmental aides, executives. We see them as the author does, as complicated, interesting, flawed, and worthy individuals.

Hospitals are political environments, as are all places where human beings work together and compete for resources, satisfaction, and respect. “Political intrigue and turf wars,” writes Julie Salamon, “were not unique to Maimonides; struggles for space, equipment, staff, and money were part of the hospital life.”

Beyond the politics and the professional jealousies, the book tells something about a hospital's stagecraft. We see the importance of medical record coding, length of stay management, case mix, and health insurance contracts. There are neighborhood politics. There are donor politics. These are unseen forces that shape a hospital world, and they help give this book its fascinating reality.

Despite financial pressures, despite individuals who give or take offense, despite various ethnic tensions, an undercurrent of hope buoys Hospital. At one point Dr. Alan Astrow, Associate Director, Medical Oncology, reflects:

In the contemporary world, when we speak of an invisible hand that drives us, it is often assumed that we are referring to the marketplace and the invisible hand of economic self-interest. But most physicians and nurses, I think, want to see themselves as more than simply one party in a financial transaction. Why do we do what we do? What keeps us going? Not just that we ought to care but why? Faced with a suffering or demanding patient whom we might prefer to avoid, where do we find the strength to enter the patient’s room?

Here is the author herself, summing up:

Depending on the day or night, life in the hospital could seem full of exquisite promise or pointless despair…Yes, individual doctors and nurses behaved badly, sometimes inexcusably so. Clerks were rude to patients and to each other. People made mistakes. Yet I was constantly struck by the sense of urgency that accompanied desires for fairness, for compassionate medicine, for efficiency, for meaning – and yes, for cleaner rooms. Both Pam Brier and Margie Morales (a member of the environmental staff) struggled to sort the unwanted from the wanted, to make the hospital what it should be. They needed their lives to matter.

Thank you, Pam Brier, for giving Julie Salamon the ability to research and write Hospital. I'm not sure I would have been as brave.

The pneumonia deaths

A recent news report cited Community General Hospital for pneumonia death rates above the national average. The story was based on mortality statistics published by the Centers for Medicare and Medicaid Services (CMS). The mortality rates were mathematically adjusted for differences in patients' medical conditions, but the rates did not adjust for differences in mortality due to patients’ own do-not-resuscitate (“DNR”) orders.

The Post-Standard reported that for Medicare-covered pneumonia patients “the national mortality rate was 11.4 percent. Community General Hospital… had a pneumonia death rate above the national rate 15.1 percent.” In paragraph eight, the story appropriately quoted Fred Goldberg, MD, Community’s Chief Medical Officer, explaining that “these report cards do not account for...end-of-life preferences."

The distinction may be too subtle for headline writers.

Last year I wrote about CMS’ plans to add pneumonia mortality rates to its Hospital Compare website. I discussed Community’s past investigations into pneumonia deaths with respect to patients’ DNR orders – and I quoted “Mortality as a Measure of Quality: Implications for Palliative and End-of-Life Care” from the Journal of the American Medical Association (JAMA):

Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.

Following the recent news story, I again looked up the JAMA article. It said:

Treatments provided to seriously ill patients are often inconsistent with patients' underlying preferences….[T]here is a 10-fold variation in the rates of early do-not-resuscitate (DNR) orders across hospitals and dramatic variation in the proportion of all intensive care unit deaths preceded by withdrawal of life support….Such decisions may be relatively more common in the 600,000 hospital deaths that occur each year (over 50% of all hospital deaths) in patients aged 75 years or older who are at increased risk for accumulating multiple chronic illnesses.

During the period of time reported in the CMS data, the average age of the pneumonia patients who died at Community General was 83. As Dr. Goldberg reported, 93% of them had do-not-resuscitate orders.

Hospital patients who can't (or won't) leave

“Immigrants Facing Deportation by U.S. Hospitals” reports today’s New York Times about the extraordinary efforts of one Florida hospital to find continuing care, both in this country and in the patient’s native Guatemala, for an illegal immigrant who had become a de facto ward of the hospital.

Last week the Wall Street Journal reported that a Los Angeles’ ordinance makes it illegal for city hospitals to discharge to “skid row” homeless people who no longer need to stay in the hospital – this is called “patient dumping.” See “L.A. Law May Keep Homeless in Hospitals.” According to the Journal, many homeless patients simply “refuse to leave” a hospital.

Hospital, a new book by Julie Salamon, which is highly recommended, recounts the efforts of discharge planners at Brooklyn's Maimonides Hospital to find a place for a Chinese immigrant who, dying of cancer, no longer needed hospital-level care but otherwise had nowhere to go.

Hospitals nationwide deal with such situations all the time. Once a hospital has successfully cared for an individual’s acute care needs, that person may end up with nowhere to go because of deficiencies and inconsistencies in health care and social service systems.

A family may drop off an elderly parent in the emergency room, then leave on vacation or refuse to take the parent home after discharge from the hospital. If no nursing home will accept the patient, that individual becomes a border in the hospital, sometimes indefinitely.

Hospitals often help patients and families with nursing home placements by assisting with the complex Medicaid application process. It is not unusual, however, to find an individual or a family unwilling to disclose financial assets – unwilling even to sign a Medicaid application. This often means a nursing home will not accept the patient, who then remains inappropriately in the hospital.

These are called placement, transfer, or discharge problems, and few know about or understand them. As a result, such problems generate no political consensus toward a solution.

As a humane society, how do we assure appropriate levels of care for the homeless, for illegal immigrants, for the mentally challenged, as well as for those who may be willfully irresponsible?

According to the Journal: “[A]bout half the hospital’s homeless patients won’t sign discharge consent forms. ‘We can’t force them,’” says the discharge planner at one California hospital.

The Times reported that the Florida hospital’s care amounted to $1.5 million for the Guatemalan patient, but when it came to paying for nursing home or rehabilitation care, the hospital declined “to take out…[its] checkbook.” Why was that expected to be a hospital responsibility? Hadn't the hospital already discharged its (uncompensated) responsibility for acute care? Where is the nursing home industry's responsibility for continuing care? Where is the US government’s responsibility? Where is the responsibility of Guatemala for one of its citizens?

Government rules and media scrutiny are inconsistent among the sectors of the health care system. Thanks to unaligned incentives and inconsistent requirements, our disjointed health care system yields paradoxical results, as reflected in these stories from the Times and the Journal.

The test results

I am glad to say that test results received yesterday show no Legionella bacteria in the cooling tower of an office building on the campus on the Community General Hospital.

As reported in the news media (see "No more Legionella in cooling tower" on WSYR-TV), that tower has been the investigated by the hospital, along with the county and state health departments, in connection with Legionnaires’ disease. The hospital has also relied on independent experts, such Janet Stout, PhD, a national authority on Legionella and water systems.

To identify Legionella, a laboratory grows cultures of the organism from samples of water. To encourage the growth, the lab adds nutrients to a Petri dish containing the sample. The dish typically contains antimicrobial agents, as well, to inhibit the growth of other bacteria, thereby improving the chances of finding Legionella.

In the photo, above, the Petri dish on the left shows no growth of Legionella after seven days from a water sample obtained from the office building cooling tower. For comparison purposes, the lab provided me with a photo that shows what Legionella looks like (in the Petri dish, on the right) after four days of growth. The comparison sample was from a source not associated with Central New York. For a better look at the Petri dishes, click on the photo.

Behind the headlines

In the past two weeks, a number of people have asked me about Legionnaires’ disease as a result of news coverage about patients in Onondaga County, including some who visited the Community General Hospital campus.

The news media work hard to provide the facts, and the hospital has spent a fair amount of time running down answers to questions and assuring that reporters had accurate information. But Legionella is not an easy subject to pin down in a few short sentences – or in short headlines that can look somewhat alarming.

My most important message has been simple and direct: Community General Hospital has done – and will continue to do – everything possible to ensure the health and safety of our patients, visitors, employees, physicians, volunteers, and neighbors. This is our number one priority.

Our engineering staff, our clinical professionals, and our communications people have spent many, many hours in recent days assuring that we have done the right things and that we fully respond to all requests, whether from patients or staff, from the County and State Departments of Health – or from the news media.

There have been several frequently asked questions, which I answer below.

For those with individual concerns, Community General Hospital has a health info line at (315) 492-5253. Feel free to call us.

To learn more about Legionella, please visit the website of Janet Stout, PhD, and her colleagues, who are experts on the subject. Dr. Stout has worked with Community General during our investigation.

How do I know I won’t get Legionnaires’ disease on the Community General Hospital campus?

You are safe on the Community General Hospital campus. We have taken proactive measures with our physical plant and patient protocols to ensure the health and safety of everyone on our campus – and we will continue to take every step necessary to do so.

Right now the office building on our campus has one of the most studied, most tested, and most treated water cooling towers in upstate New York, if not in the entire northeast. The New York State Department of Health continues to monitor the situation and has said there is no information to suggest any ongoing exposure on the Community General campus. Our hospital continues to work collaboratively with both the Department of Health and the Onondaga County Health Department.

A member of my family – and I personally – have sought care at Community within the past several weeks.

News reports said that an office building cooling tower on the hospital campus tested positive for Legionella, even after a first disinfection. What are you doing about it?

For years Community General Hospital has proactively treated cooling towers using outside water treatment experts – and will continue to do so. From the very first signs of concern, the office building cooling tower was disinfected using a chemical shock treatment to eradicate the presence of Legionella. A second disinfection process, about ten days after the first, was undertaken before we received any test results from the first one. The second disinfection used a 48-hour treatment program recommended by independent Legionella experts and the Centers for Disease Control. We felt this was an important precautionary measure. Preliminary test results indicate that this treatment was effective, and we await final results.

Is the office building cooling tower the source of the outbreak?

Although the cooling tower has not been confirmed as a source of the Legionnaires’ outbreak, we have acted as if it were, taking all the steps necessary to increase treatment and to measure results. Health officials have told me they continue to investigate other possible sources within the county.

Have any patients or hospital employees contracted Legionnaires’ disease?

Our surveillance program for diagnosing Legionnaires’ is very aggressive. No patients or hospital employees have been known to have contracted the disease. We have gone back and identified with employees who were ill and asked them to take a test for Legionella. All results have been negative.

Of the 13 cases identified as having Legionella in Onondaga County, Community General Hospital has firsthand knowledge of six who were treated at the hospital or by members of the medical staff. None of them are believed to have contracted the illness while in the hospital.

Am I able to drink the water at Community General Hospital?
Yes. The water is safe to drink. Patients are reminded to follow physician and nurse instructions.

Where does Legionnaires’ disease come from?
Legionnaires’ disease is caused by the Legionella bacteria, which is found naturally in the environment, usually in water. Legionella is very common, and small traces of the bacteria can be found in most water systems.

How do people contract Legionnaires’ disease?
People contract Legionnaires' disease when they breathe in a mist or vapor (small droplets of water in the air) containing the bacteria. The disease is not spread from person to person, and is most commonly found in people who smoke, who are 50 years of age or older, and who have a chronic lung disease or immune deficiencies.

What are the signs and symptoms of Legionnaires’ disease?
Although most people exposed to the bacteria do not become ill, Legionnaires' disease can have symptoms similar to other forms of pneumonia. Signs of the disease can include a high fever, chills and a cough. Some people may also suffer from muscle aches and headaches. Should you experience any of these symptoms, please contact your health care provider.

Today's Legionella announcement

This afternoon Dr. Cynthia Morrow, the Onondaga County Health Commissioner, announced that seven cases of Legionnaires’ disease were reported in the county over the past ten days. This includes four unconfirmed cases that Community General Hospital reported last week.

Obviously, there's a fair amount of news coverage this evening, including The Post-Standard, and Central New York television stations WSYR, WTVH, WSTM, and News10Now.

The Department of Health’s preliminary investigation identified that all of the unconfirmed cases were on or near Onondaga Hill, including at Community General Hospital. The source of this cluster of cases has not yet been determined.

Last week Community supplied the Health Department with water samples from both the hospital and the physicians’ office building cooling towers. In addition, over the course of the past several days, Community has undertaken additional measures involving experts in water treatment to assure disinfection of the cooling towers. Keeping Legionella below detectable levels in cooling towers at all times is practically impossible due to the ubiquitous nature of the bacterium, according to the Association of Water Technologists.

Community has routinely tested the hospital’s cooling tower and water supply. Also, Community has for years been one of the relatively few hospitals that actively tests for Legionella all patients who have pneumonia.

The office building cooling tower did recently test positive for the bacterium. In cooperation with the Health Department, we completely disinfected and sanitized that tower to eliminate the bacterium (even before test results were received).

Dr. Mitchell Brodey, Community’s Infectious Disease Specialist, and Sue Chamberlain, RN,CIC, our Director of the Infection Control Program, have been fully engaged with surveillance and with communications with the Department of Health, as has Community's engineering staff. We are glad to work with the state and county health department professionals, and we will continue to do so.