Tuesday, August 16, 2011

Ninth Chapter

Ninth Chapter


In which we see how uneasily the crown lies on the head of the OR

   Chicky sat down at her desk and sighed deeply. She had just returned from a meeting of the OR committee. As always it was a trial by fire, with the surgeons in an uproar. It was a misconception to think of them as a group. They were actually a pack of rabid individualists, each pursuing his own goals and the devil take the hindmost. Trying to get the committee to move in the same direction was like trying to herd cats. Cats that varied from grumpy to angry.

   When Chicky first took over the OR, the problem was scheduling the surgeon’s procedures. Space on the OR schedule was given on a first come first served basis. This had led to numerous problems. Surgeons would book fictitious patients when they did not actually have one, so as to save a favored time in the schedule. Often they would then call in a change, putting a real patient in when one came along. If they didn’t have a real patient, they would simply cancel the fake one. Sometimes they would forget to cancel the fake patient and much time would be lost trying to locate the fake, and a hole in the schedule would result, and there would be lots of difficulty in trying to rearrange the schedule at the last minute. Sometimes the fakes were easily spotted: Clark Kent, John Smith and Jane Doe were frequent entries on the schedule. The first effort to deal with this situation was the Chief of Surgery’s idea. Patients could only be entered on the schedule after they were registered with the hospital and assigned a medical record number. This led to some more counter tactics: posting patients who had been patients in the past, so there was a valid MR number. Or posting a patient who was actually in the hospital but would not be coming to the OR for surgery. The most egregious example was when Dr. Syriani booked a patient, then forgot to cancel when he didn’t have a real one to substitute. Many phone calls were made trying to locate the patient in the hospital, and on the last call it was found that the patient in question had died a week earlier. This led to many jokes about Dr. Syriani’s bedside manner, and that he made a specialty of operating on dead people.

   Chicky’s idea for solving the scheduling problem was to assign each surgeon a block of time that would be held for him up until twenty four hours before surgery. No need to fill in with fake patients, dead or otherwise. The problem the idea posed for the surgeons had to do with when the blocks of time would be. They all wanted to start first thing in the morning, and time in the afternoon was not as desirable. After all, what every surgeon wants is to have an OR staffed and ready for him twenty four hours a day, never mind that he would only use a small fraction of that time. An MBA candidate did a thesis which showed that the cost of maintaining an OR at the ready was about $120 a minute. This included all the overhead, such as HEPA filtration in the air handling, heating and cooling, electricity, salaries for nurses, techs and anesthesia, depreciation of equipment and instruments, generating and maintaining pressurized steam for autoclaves, gasses piped in such as oxygen, compressed air, nitrogen, nitrous oxide, and many other items. This study was published in a number of medical and nursing journals and made the all-time hit parade for OR managers. The surgeons were less than impressed. After all, it didn’t cost them anything. Chicky always wondered at the privileged position surgeons enjoyed. What other profession was there that someone else hired all the help, bought all the tools and equipment, carried all the overhead, and then begged you to come use it for free?

   It took a year and a half of intense politicking to get block time approved. The surgeons of course were the most vocally opposed to the idea. Chicky was barbequed at several OR committee meetings before block time was implemented. The surgeons with the largest case loads got the prime start of the day time and the smaller case loads the less desirable afternoon time. The gaming of the system was not over however. Now surgeons booked their cases for shorter than actual time to get more into their block, or exaggerated the time so as to fill their blocks. This meant that afternoon blocks were delayed because morning blocks ran over, afternoon blocks ran over, and staffing budgets were out of whack because a lot of overtime was needed to cover the overages. Conversely, when times were exaggerated to fill blocks there were holes in the schedule. It was often remarked that the OR schedule was in the running for the Pulitzer Prize for fiction. Chicky lost two very good nurses because they couldn’t get their children out of day care by the time the daycare facility closed.

   Molly came to the rescue by writing a computer program that tracked the times need by a surgeon for a given procedure. It took the times for the last ten times he did the procedure, tossed out the longest and shortest time and averaged the remaining eight. This was the time entered in the schedule when a surgeon booked a case. Cases that ran over the block were put on an add-on list, and worked into the first available spots, usually when block time was unused twenty four hours before the day of surgery. Alternatively, it was put in the surgeons next block. True emergencies bumped block time, but these were surprisingly small in number. This worked out very well, the overtime came within budget, the nurses, techs and anesthesia providers were happy with much more regular working hours, and even the surgeons were a lot happier after they got used to it.

   Now the issue was on-time starts in the mornings. Chicky and Molly had been collecting data on delays to first case starts and the reasons for the delays and who was the person responsible for the delay. Out of 336 first cases in the study, 161 were delayed. 153 were delays due to surgeon problems, such as patients showing up without History and Physicals (H&Ps), admission orders, or surgical permits: all of these were clearly things that the surgeons should have taken care of. There were 6 delays caused by the nursing staff, and they all had to do with equipment problems, three of the six were considered to be problems that could have been avoided. There were 2 delays on anesthesia’s tab, both due to serious medical problems that had to be resolved before surgery could take place. Chicky didn’t need a crystal ball to know that she would need to bring the barbeque sauce to the next OR committee meeting. The surgeons were not going to be willing to consider that they were the chief cause of morning delays.

   The next thing on Chicky’s list for the day was the yearly evaluations of her staff. This was a very complicated business, as the hospital had implemented a “merit based” system for raises, computed from the scores on the evaluations for each nurse or technician. In reality, it was a forced distribution system. If it had been a true merit based system, the amount of money to be awarded in raises would not be fixed. The reality was that Chicky got a sum that would provide all her people a 2% raise. So if she gave someone 3%, she had to give someone else 1%. So the scores had to be juggled to make everything come out even. Chicky knew that her people had worked hard all year, and having had this “merit based” system spun up to them in staff meetings and flyers posted to their homes by the HR department, they would be expecting a payoff. It was going to be a big disappointment. Maybe she should just order a case of BBQ sauce.

   While she was contemplating the “merit based” fiasco to come, there was a knock on her door. Chicky called out “come on in”. Linda entered the office, and closed the door behind her. She looked very upset. Chicky motioned to her to sit and extended the jar of jelly beans she kept on a corner of her desk. Chicky often joked that instead of jelly beans, her jar should contain capsules of Prozac. Linda shook her head, declining, and launched right in. “It’s about Connie.” She went onto relate how she knew that Connie had been having a lot of problems lately, and had been drinking hard. In fact she had shown up for work today visibly impaired. “I don’t want to get her fired or in trouble, but something has to be done.” Now the policy of the hospital was that any employee suspected of intoxication was to be taken to the ER and blood drawn for a toxicology screen. If drugs or alcohol were found, they were to be terminated on the spot. However, if an employee went to employee health and turned themselves in, admitting to a dependency problem, they would be sent to rehab, and could keep their job. Chicky decided to go out on a limb. “Bring Connie to my office” Chicky instructed Linda.

   When Linda returned to the office with Connie in tow, Chicky told Linda to wait outside, and had Connie sit down. Chicky got the aroma of alcohol on Connie’s breath as she started to cry. Chicky gave her a tissue. She reached into her book case and removed one of the many three ring binders there. Chicky thumbed through it, and reaching the section she was looking for and gave it to Connie. It was the section of the HR manual detailing the policies about dependency. “I want you to read that carefully before you say anything to me. “ Connie made as if to speak, but Chicky cut her off “Don’t talk, read” she said to Connie. Connie read. “Now,” said Chicky, “do you want to go to employee health?” Connie nodded yes. “Do you know what you have to do?” Connie nodded again. Chicky went to the door and told Linda “I just had you come to my office, and you don’t know anything about what is going on with Connie, comprende? Don’t answer that. Please escort Connie to employee health.” After they departed, Chicky sat back in her chair and breathed deeply, letting it out slowly, repeating it again and again, waiting for the relaxation to start. She knew that a similar situation with one of the anesthesiologists last year had not turned out well, and hoped that this would turn out better.

   In preparation for the OR committee meeting, Chicky was running through the on-time report with Dr. Hunter, the Chief of Surgery. He agreed with her that it was going to get a contentious reception. Chicky shared with him part of the data collected that was not included in the report. It showed that an overwhelming number of the surgeon related delays were accounted for by only eight surgeons. Another group of twelve had only one or two attributed delays, and another group had none at all. “I want to get all the bluster out front and let the steam out before making these figures known” confided Chicky. “You notice that the biggest offenders are also the ones who make life difficult?” Dr. Hunter agreed: “The way forward as I see it is to ease this in at a later meeting, but only after I have let it be known to some of the guys who always come in with their ducks in a row. Maybe we could get some peer pressure built up before we make this public, and get the committee to come up with some ideas to remedy the situation.” “Then you and I will not have to come off as the heavies and the opposition to the community of surgeons” said Chicky. They nodded to each other. Since the block time plan had created a stable and realistic schedule, Dr. Hunter had come to trust Chicky and worked very closely with her.

   It was eight weeks later, and Chicky was driving past the tall stone pillars and large wrought iron gate of a country estate that had become one of the better private rehab clinics. She was there to meet with the Director of the clinic to prepare for Connie’s upcoming discharge and return to the work place. The hospital had arranged for the best for Connie. After parking in the shaded and landscaped parking lot, Chicky walked up the short flight of stairs to the ornate doorway. The impressive manor house had been built at the end of the nineteenth century by a robber baron who had made his fortune in making saws and other hand tools, and later on arms and ammunition for the Spanish-American war. It had gone into decline in the sixties and was bought by a foundation and renovated into a clinic specializing in drug and alcohol rehab for those of means and requiring discretion. She was met by a receptionist and shown to an office, every horizontal surface of which was piled with journals and papers. The director of the clinic arose from the organized chaos and introduced himself. He got right down to business and detailed the requirements for Connie’s return to work. It was all pretty much as Chicky expected except for one thing: Connie could not work in an area where there were any controlled drugs, nor could she have access or administer them. This told Chicky that Connie’s problem was not just with alcohol, a surprise. When Chicky questioned the director on this, he dodged the question, and reiterated those conditions. This was going to be a problem. Chicky said she would get it worked out and was given a copy of the schedule for follow-ups that Connie would have to keep. Chicky also had to report the whole business to the state board of nursing. They would have additional requirements that would have to be met.

   Chicky created a position to put Connie into. Connie would be calling all the surgeon offices and following up on getting all the H&Ps, permits, copies of x-rays and lab work either mailed or faxed into Connie's little office, where she would collect the paper work into files to be delivered to pre-op on the day of surgery. Hopefully, the surgeons would see this as a customer service initiative instead of nagging. She would also contact the patients on the day before surgery and go over things with them. She would also make follow up calls to patients to check up on how things were going for them. This not only would meet the conditions for Connie’s return but should solve a good many of the delay issues as well. The OR committee had not been able to get past arguing about the delays. The public relations aspects would please the hospitals marketing department. That had been a big help in selling this position down on mahogany row. And it would also help the bottom line of the OR as well, since at $120 a minute, it could cover the cost of Connie’s position by reducing unproductive OR time. But most important to Chicky, it meant a chance at recovery for Connie as well. Still, the fact that drugs had been involved, and that no shortages in the inventories had been noticed, bothered Chicky in the back of her mind. When things had gone this way with one of the anesthesiologists, there had been drugs missing from the inventory, vials of drugs that had been watered down, and two rounds of rehab had failed. It had ended with a funeral. As it was, Chicky was going to have to report on Connie to the state nursing board weekly. Connie would also be subject to weekly and random drug testing. Chicky sat back in her chair and started to breathe in deeply, letting it out slowly…..

Sunday, August 7, 2011

Eighth Chapter

Eighth Chapter
In which the history of hospitals, nurses and gender roles affect the present.

   In the beginning there was the Pennsylvania Hospital in Philadelphia. As with so many other institutions in that city, Benjamin Franklin was one of the founders. There were no trained nurses in those days, just women from the almshouse who worked in return for room and board. The hospital was in effect a family, and these women were the self sacrificing caretakers of that family, doing the housekeeping, laundry, cooking, bathing, etc. The Doctors were of course the head of the hospital family, and enjoyed all the perks and privileges. Remember too, that in those days bathing was believed to not be a healthy thing to do on a regular basis. Medicine itself was full of dangerous treatments such as bleeding and purging and even the use of animal dung and herbs as poultices for wounds. Hospitals were for the “Deserving Poor”, meaning the employed working class. Indigents need not apply. Wealthy people were cared for in the home.

   All this began to change with the Crimean war in Europe with Florence Nightingale, and the Civil war in the US with Clara Barton. The need for hygienic conditions became apparent, medicine began to be practiced on a scientific basis, and the need for a more trained workforce was recognized. The nurses now were those women of the working class who had to provide for themselves, and did not qualify as governesses or maids, the other legal occupations open to independent women. They were still seen as the caretakers of the hospital family, and got a meager wage, if any, as well as room and board. All respect and obedience was due to the heads of the family, the Doctors.  As medicine advanced, this evolved into an apprenticeship model to train nurses, and the hospital school of nursing became the norm. Every hospital had one. At the same time, Doctors began to look at the practice of medicine as a business, and the hospital as their enterprise. Labor costs need be contained of course, so there was a great incentive to use the apprentices as an unpaid or lowly paid work force, so there was little need to employ the graduates of these programs. They were only there for the good of the family anyway.  A few graduates were employed as supervisors. Other graduates worked for the wealthy in their homes on an as-needed basis.

   World War Two brought the next significant changes to nursing. Practically overnight, the need for a highly trained workforce of nurses materialized. The military establishment saw the need to regularize this workforce, to give them advanced training, and pay them accordingly, which led to commissioning them as officers. Before this they were just volunteers, with minimal sort of training. However, with the war over, the need shrank, and most of this cohort married and entered civilian life. Hospitals still needed this workforce so the apprentice system expanded and the employment prospects for graduates grew. Graduates staffed the days, apprentices the night shifts and weekends. Nurses were still the caretakers of the hospital, and expected to be totally self sacrificing. Nurses were explicitly excluded from basic labor laws such as Taft-Hartley, minimum wage, overtime, etc. Pay was not good. As recently as the late seventies nurses did not make as much as grocery checkout clerks.

   The next significant change was the explosion of technology in medicine. More people were in hospitals for more and more complicated procedures and treatments. Suddenly there was a large shortage of nurses. To further complicate the picture, the organization that accredited nursing schools banned the use of students to staff hospitals. Hospital schools of nursing began to close everywhere. There was no incentive for a hospital to have a school if it was not a source of cheap labor. The nursing shortage grew; wages climbed, and into this milieu entered Anne.

   Anne was a looker. She turned heads on the street. She had begun to notice the effect she had on men when she was a teen. People always told her that she should be a model, an airline stewardess or that she should enter beauty contests. None of those things interested Anne. She learned to divert men’s advances with a joke, or failing that, a verbal slap. Boys her own age generally fell into two categories: the ones who became awkward and shy, or those who became showoffs, boastful and silly. There were problems with cliques among girls, some very jealous of the attention she received from the Don Juans. In high school, she became interested in biology, and won a science fair second place with a project on the effect of various metals as antibacterials. Because of her looks, she got more of the local media attention than the first place winner, which distressed her. She moved on to the State University, where she decided that nursing was what fit her interests best. She grew to despise the frat men and jocks that plagued her initially, and then spread stories of her supposed frigidity in the wake of her refusal of their advances. And other male students were intimidated by her looks. Contrary to what people expected. She had very few dates. And there was one faculty member who seemed oblivious to her refusals. Fortunately, graduation came before the problem became serious.

   Her first job was on a surgical floor in a community hospital. Her college experiences with amorous men prepared her well for dealing with the residents and attending doctors. They pretty much fell into the same categories as college boys, and could be handled the same way. Her best friend growing up was the daughter of a doctor, so she had no illusions as to what marriage to a physician was like, and it was not what she saw for herself. There was one nurse she knew who was determined to land a doctor, but it had no appeal to Anne. To be fair, there were Med students who looked to land nurses for the support they could provide through med school and residencies. It worked both ways. There was Dr. Shulz., A kindly older surgeon, who was a reflexive flirt. He flirted with every female in sight, never pushed things past that. Flirting was the sport in his life. Anne actually came to enjoy the good natured exchange with him, and it was a spot of brightness in her day when he was on the floor. It was said of Dr. Shulz that a woman should only take offense if he didn’t flirt with them.

   Checking the jobs board outside of the cafeteria one day, Anne saw that there were two openings for OR nurses. Anne put in her application immediately and was accepted a short time later in large part due to her reputation as a superior nurse on the floor. Anne took to the OR like a duck to water. After she had been there for a couple of years, the OR had to bring in several agency nurses to cover vacancies that could not be filled due to the nursing shortage. If there was a shortage of nurses generally, there was an acute shortage of nurses in highly specialized areas such as the OR and intensive care. The agency nurses worked on thirteen week contracts, were paid almost double what the going rate for staff nurses was, and had the opportunity to work in exotic locations such as Hawaii, California, Aspen Colorado and Florida. It appealed to Anne enormously, and she signed on. Having a contract gave a nurse a great deal of autonomy, and got one out of the politics involved in being a regular staff member.

   At her last assignment as a “traveler”, as agency nurses were often referred to, Anne encountered her first really serious problem with a surgeon. Dr. Epsom was the chief of surgery, and pursued Anne relentlessly. He had already been married and divorced three times, and had a reputation as a skirt chaser. Unable to take a hint from the humorous deflections, he then took offense at the verbal slaps. He seemed to believe that he was entitled to what the French would call “les amours ancillaires”, or having a tumble with the hired help, and "who was this traveling gypsy to refuse him."

   One day in the OR, Anne was circulating on one of Epsom’s cases. The anestheologist was having difficulties; the anesthesia tech was not answering pages, so Anne had to leave the room several times to get things for the anestheologist. Dr. Epsom’s temper was triggered and he flew into a rage, threatening Anne “If you leave this OR one more time, I am going to tear those tits of yours right off and feed them to the crows”. The room became deathly silent. One felt as if frost could be scraped off the walls. When the procedure was over, Anne typed up a letter describing the incident and got the anesthesiologist and the scrub nurse to sign it as witnesses. The resident who was assisting Dr. Epsom refused, and it was understood by all that he could not afford to cross the chief who could derail his career. Anne took the letter to the office of the president of the hospital and made the receptionist sign for it.

   The next day when she reported for duty, the OR supervisor directed her to report to an office in the human resources department. Inside the office Anne found a chair facing a table with four people sitting at it. Anne was directed to sit down. Feeling like she was facing a firing squad, Anne sat tall, knowing she had a contract as a”traveler”, something staff nurses never had from hospitals. She was also confident that her agency would stand behind her. The people behind the table were introduced. The Vice President for Patient Care, the Corporate Counsel, the Vice President for Human Resources, the Chief of the Medical Staff. After a lot of hemming and hawing and talking around the subject, Anne was given the opportunity to say her say. It was obvious that the brass behind the table feared a lawsuit. Anne told them “I don’t want your money; I don’t want Epsom’s money. I want him to be disciplined just as you would discipline anyone who verbally assaulted another person working here.” There was more hemming and hawing and she was dismissed with a “we’ll get back to you.”

   Anne left the hospital with a sense of foreboding, and stopped off at a shopping center on the way home, picking up several items at a couple of different stores. Arriving home, Anne called her manager at the agency she worked for. Her manager, Kelly, confirmed that she had received a copy of the letter Anne had delivered to the president of the hospital. Kelly told Anne “The agency is behind you one hundred percent, call me as soon as you get a response from the hospital.” That left Anne feeling much better. Having her agency behind her with the force of her contract was very reassuring.
   The next day when Anne arrived at work, she was told to go to an office in the administrative wing of the hospital immediately. Arriving at the door of the office, she saw from the nameplate that it was the office suite of the corporate counsel. She went in and the receptionist took her straight back. Anne wondered over the fact that the receptionist did not ask for her name and that she had been taken straight through to the big man’s inner office. Anne removed a pen from her bag along with a small memo pad. She was directed to a comfortable chair directly in front of the attorney’s desk. The attorney jumped right in, and Anne fiddled with the pen, placing the memo pad on the edge of the desk. “You won’t need that, there is actually very little to discuss.” Anne replied to him “Actually, I am informing you that this conversation is going on record.” The attorney countered “A court would not consider notes that you take to be a proper record you know.” “Never the less, I am making a record of this conversation with this pen. Do you understand?”rejoined Anne. “Oh, alright if you must.” replied the attorney. ”As for Dr. Epsom, we do not feel that there is anything in this incident that the hospital needs to address with him. We have also come to the decision that your services are no longer needed here.” With that a security guard entered the office carrying a cardboard box with Anne’s belongings from her locker. She saw the lock on top; the hasp had been cut with a bolt cutter. “The officer will take your ID badge and escort you from the building. You are forbidden to enter the premises again, and if you do you will be prosecuted for trespassing.” The officer took her to her car without comment. Anne called her manager on her cell phone and told her what had occurred. Kelly told Anne “We will see about this. Your contract specifies that you can only be dismissed for a failure to perform up to standards, or misconduct.” “Our position will be that your dismissal is a breach of contract, and the hospital will have to pay off the contract along with a penalty for early termination.” “Of course you will be paid for the remainder of the contract.” “I would also urge you to contact an attorney and pursue the hospital and their chief of staff.” “Our attorney will find someone in your location that you can talk to.”
   A short time later Anne got a call, it was her agency’s attorney. He gave her the name of someone he knew in the city, a fellow who was a classmate of his from law school named Steve. Anne called and set up an appointment for the following day. Steve welcomed her warmly, took her to a very plush conference room, coffee and pastries were served, and they got down to business. Anne presented a copy of her letter, copies of her weekly time sheets that the OR manager had to sign each week. These time sheets also had on them an evaluation of Anne’s work. The evaluations were uniformly excellent. Steve was impressed. Then Anne produced the pen she had bought at Radio Shack, and played the recording for Steve. He laughed out loud. The pen was a digital audio recorder, and had recorded the hospital’s counsel clearly. “That way you got him to agree to being on record was very clever. In this state as in many others, it is illegal to record someone without their consent when they are in a place where they have an expectation of privacy. That’s why businesses customer service phone lines always give you the message that “Your call may be recorded for purposes of quality assurance”. Its total bullshit, it has nothing to do with quality assurance. They are actually getting a record that possibly be used against you if necessary.” We have several options here. You could file a complaint for second degree assault, a criminal charge. Making a threat of physical harm qualifies as assault under this state’s laws, but that could take a long time perhaps a year or more to come to court, the DA’s office would not give it a very high priority. And of course, your surgeon’s counsel would delay and delay, hoping that you or the witnesses would move, lose interest, or otherwise become unavailable.” You have grounds to file suit as a civil matter, against both the surgeon and the hospital, and I would recommend filing a complaint with the state medical board as well. The Board will probably not do much beside say “Bad boy, don’t do it again or we might make you take an anger management class”, but it would bolster your civil case to have them on record that the surgeons conduct was an offense.” A deal was struck that Steve would get one third of whatever he could get from the hospital and the chief, Anne two thirds. Steve predicted that he could bring the matter to an out of court settlement in less than a fortnight, once the other parties understood the case against them. Steve would carefully calibrate the damages sought so that it would be cheaper to settle than fight, and he would raise the aspect of adverse publicity as well." I have a good friend who is a reporter for the city's newspaper. We can apply some pressure that way as well." Steve said. Anne felt great. Without a contract, as would be the case if she was an employee of the hospital, she would have been without recourse. And it was great to have the full backing of her agency.