Hospital

by Julie Salamon

  At Maimonides, Olendorf started carrying around a Curious George lunch box. She said she wouldn’t have felt comfortable doing that at her old job, but somehow this oddity now made sense. She explained that the lunch box prevented her from ever forgetting about patient flow.

  How?

  Olendorf had originally been hired at Maimonides as a performance-improvement specialist, responsible for understanding breakdowns in the system through data.

  “There’s a theory of asking why five times, and you’ll get to something you can actually fix,” she said when asked about Curious George, whose imprint wasn’t limited to the lunch box. Olendorf’s office had become a Curious George museum, filled with Curious George dolls, mugs, and clocks. “Early on, I got a reputation for asking, ‘Why do we do it this way? Why does that happen?’ So the second year I was here, during the holidays, someone bought me this Curious George lunch box. So I carry it. It has pens and pencils and a calculator, Kleenex, markers, tape—management tools of facilitation. And now everyone brings me Curious George paraphernalia.”

  Olendorf had generally lived her life as the good girl. Her mother ran a grocery store, and her father worked at a steel company. Neither of them went to college, but they were ambitious for their children. She had no choice but to try to succeed. Yet after working her way through nursing school, Olendorf was burned out. She took a sabbatical from responsibility, packed her trunk, and headed for Aspen, to learn how to ski.

  At Maimonides she saw the chance to combine responsibility and the thrill of the unknown, in a way that suited her in her fifties. “I need constant stimulation to get to the next good idea, and here everything was magnified and amplified,” she said. “The place always feels sort of on the edge—on the edge of breakthrough of learning and improvement, on the edge of catastrophe because so many things can go wrong.”

  The hospital had hired a headhunter to find someone for the performance-improvement job in 1995. When the headhunter contacted Olendorf, an early adapter who had been doing that kind of work for a decade, she said no, she wasn’t a city person. A conversation with someone who knew the hospital convinced her to take a look. She was fascinated by the different types of people, the lines queuing up at the clinics, the strange little brownstones (that weren’t brownstones) that housed many of the administrative offices.

  Her husband was ready to make the leap; he had retired from the building business and was making furniture at home. They surprised their grown children: “Hey kids, we’re moving to Brooklyn, New York.”

  The door to her office remained open; at first glance the office usually seemed empty. A closer look would reveal Olendorf hunched in front of her computer screen, which provided the only light in the room. She puzzled things through in the dark, a way to shut out the static. It wasn’t noisy on the executive floor, but there was a lot of nervous energy. “We’re overstimulated, overinterested,” said Olendorf.

  Even sitting unobserved in the dark carried risks. Once, in the early evening, when it was already night outside, Brier came into Olendorf’s office unannounced, with a physician, to steal some cookies sitting on a table by the door. The director of nursing sat in the shadows holding her breath, hoping they wouldn’t notice her.

  Olendorf had been instrumental in improving the nursing staff’s performance and morale, which was at a low after the 1998 nurses’ strike. She managed to be rigorous without insulting anyone, which Douglas Jablon— vice president for patient relations—interpreted as a kind of miracle. “With Sondra Olendorf, I feel she dropped from heaven, and I don’t even think she got hurt,” he said. “I say when God created her, God was just showing off. I remember before her we went through three, four nursing directors. I won’t say they were all hated, but nurses didn’t want to talk to them. Sondra walks on the floor and they throw themselves at her, kissing her.”

  In 2000, after she had become head of nursing, Olendorf asked a group of nurses to patrol the hospital to look for problems. They found several:

  Patients would be scheduled for discharge, and then the doctors wouldn’t pick up the lab work in time for the social workers to reach family members to pick the patients up. It was taking the cleaning staff eight and sometimes ten hours to get a bed washed, when the actual washing took about twenty minutes. Nurse-to-patient ratios on many floors were one to eight, requiring herculean effort on the part of every nurse; if a patient was discharged, there was little incentive to rush to fill that eighth bed too quickly.

  Yet five years later, the problems continued, even after more nurses were hired and more social workers were replaced by discharge planners. Patients aren’t fungible. They had to be distributed by disease and potential for infection, and available beds didn’t necessarily crop up where they were needed. “You have to look at the entire picture,” said Theresa Romanelli, a nurse on the telemetry unit who had been at Maimonides eight years and been chosen to become one of the “bed managers.”

  “We have twenty empty beds in surgery, no beds in medicine, and ten people waiting in the emergency room. We’re not going to leave those beds empty. When it’s really bad, in the winter months, we’ll borrow beds from telemetry. But the next day they may be overwhelmed.”

  Being a bed manager took Romanelli outside her zone in the hospital and sparked a kind of existential awakening. She had never thought about her unit in relation to the rest, apart from maybe housekeeping and pharmacy. Who has time to reflect on all the links in any chain, how the envelope you put in a mailbox ends up at your mother’s house a thousand miles away, or how freshly washed lettuce ends up in a sealed bag on a grocery shelf, or where electricity comes from, or how patients suddenly appeared in her unit? Suddenly she saw herself and the work she had done as both larger and smaller, part of a giant equation she hadn’t even considered. “Coming from the floor, I was able to see the entire hospital,” she said. “I just didn’t think of anything outside my unit before. I just didn’t. You go to work, you go to your area, you do your shift, and you just leave. You aren’t aware. You have this notion you are working so hard, harder than anyone else. Then you start walking around and you see everyone working so hard. You’re so consumed with your own thing.”

  The fact that Maimonides is a teaching hospital added to the complexity. As in most hospitals, the residents belonged to teams. The six medicine teams, for example, distinguished themselves by color: Purple, Yellow, Orange, Green, Brown, Black. Each color had a home floor, and patients were admitted on a rotating basis. So when a doctor from, say, the Brown team came down to “take report,” to prepare for the handoff, the trick was to find that patient a bed on the floor where the Brown team was stationed.

  The bed managers asked for and were granted an overflow unit, a grouping of rooms that could accommodate patients with a variety of illnesses. But every morning the infectious-disease team patrolled looking for “Contact P,” as in pan-resistant, patients requiring isolation because they carried bacterial infections that had become resistant to commonly used antibiotics. The special precautions had begun in 2004, when there was a noticeable increase in patients infected with these supercharged bacteria.

  “They’ll call up to four P.M. and say, ‘This patient is now Contact P. You have to move this patient,’” said Romanelli. “These biology majors ruin the bed manager’s day. You think you have everything right, you think you can predict, you know what surgery is going on, then you get a call—‘We have four new Contact P patients’—and it’s chaos.”

  Romanelli often felt overwhelmed. “Sometimes I feel responsible, if someone is waiting in the emergency room for a day, waiting for a bed, [and] despite bed management, despite overflow, despite everything else, we just don’t have the space, we don’t have the room,” she said. “You can have ten discharges planned, and within minutes ten discharges can be canceled. Things just happen.”

  When things just happened in health care, someone found a moneymaking opportunity. A company called TeleTracking Technologies
created software to deal with the bed-tracking problem. In 2005, frustrated by its inability to speed up the flow, Maimonides management decided to spent the money— $408,000—for an automated system from TeleTracking Technologies.

  The company’s Web site explains how it is supposed to work:

  When a nurse requests transport for a patient who is being discharged, it starts a chain reaction. As the transporter leaves a room, he or she calls into Transport Tracking, which prompts housekeeping through Bed-Tracking. Then the housekeeper arrives and dials in. In the Patient Logistics department, staff members see that the room’s status has changed to “In Progress” on the screen. When the housekeeper dials in that the job is complete, the system changes that room’s color on the screen as it is designated “Clean.” This allows all departments to easily view bed status.

  Maria Ferlita was impressed by the new system, which had just been put in place. “Oh, my God, I’m going to go blind there with all these colors,” she said. “But now we can look at that board in a snapshot and see which bed is empty, which one is being cleaned, which one is male, which one is female, and it will allow us in one view [to see] what is going on [on] each particular floor and everything else. This will help us produce the system electronically. This will help show us where the problems are. I think long-term what it’s going to do is reduce the amount of dead bed time tremendously.” She was willing to be hopeful.

  A few months later, I checked in with Olendorf, who said the flow was better but the smooth transitions described by TeleTracking Technologies were still elusive. “I can be accused of a lot of things, but I won’t be accused of kidding myself,” she said. “If you want to fix things, you have to admit they’re broken.”

  They had learned that for the bed-tracking system to work, someone at the nurses’ station had to let the system know that a patient was ready to be discharged. This required punching a bunch of numbers into a telephone line. The job fell to the “information specialists” on the unit, who already had a long list of responsibilities. None of these duties involved clinical expertise, but they were the jobs that could make a hospital stay pleasant (that is, at least tolerable) or a nightmare.

  The job description listed twenty-six tasks that included being receptionist and traffic cop for patient and visitor questions and needs; taking care of charts; notifying physicians, nurses, and dietary staff of arrivals and departures (via admissions, discharges, death); distributing mail; overseeing patient property; running errands. Now managing the bed-tracking system had been tacked onto the load of the lowest-paid people on the nursing staff, annual salary about $23,000.

  “You have to be reasonable about what you can expect for what we’re paying them,” Olendorf said. Yet she was willing to raise expectations, hers and theirs, and made plans for yet another new training program. “People have to change their process to be watching instead of waiting for someone to call them or beep them. If we change that, it will greatly reduce potential errors. I think it’s going to work, but you can’t kid yourself about the implementation. You have to keep changing, and people have to change their practice.”

  The term “dead beds” had additional meaning in the hospital world in New York State. While Maimonides was overflowing with patients, about twenty other hospitals in the state had closed in the previous five years, for various reasons, including mismanagement and not enough demand, but all related to business. St. Mary’s, for example, the hospital in Crown Heights that catered mostly to poor people, had been operating at about 57 percent capacity when it stopped operations in October 2005. A group called the Berger Commission, named after Stephen Berger, the former government official and investment banker who headed it, had been circling over the state’s hospitals like the angel of death and eventually would announce its hit list.

  About two and a half miles from Maimonides, another hospital was in trouble—Victory Memorial, whose very name now seemed like a portent of its own doom. This 250-bed hospital, which also had a 150-bed nursing home, situated across the street from a golf course and from the bucolic campus of Poly Prep Country Day School, conveyed the placid feeling of a hospital in a small city. Founded in 1900, Victory had not adjusted to the changes in hospital finances brought about by managed care; it had been operating in the red for the past two years. A number of doctors affiliated with the hospital had moved their practices; the hospital was generally running at 75 percent occupancy.

  State and local politicians did not want the hospital to close; the institution employed 1,000 people and delivered 2,500 babies each year. But obgyn was a money loser. Reimbursements were low, malpractice premiums enormous. The only thing that might keep Victory alive was the fact that it had a middle-class constituency with political clout—unlike St. Mary’s, located in Crown Heights, a poor neighborhood. Martin Golden, state senator for the Twenty-second District in Brooklyn, had been born at Victory. After a couple of failed attempts at partnerships with other Brooklyn hospitals, the state had asked Maimonides to get involved.

  Brier was eager to do so. Victory and Maimonides entered into an uneasy partnership, overseen by state officials, under which Maimonides invested $5 million in Victory, mainly to cover payroll and other expenses. Maimonides was supposed to help Victory increase admissions and improve its finances, a task that fell to Fraidkin, Cunningham, and Robert Naldi, the chief financial officer. The return to Maimonides was murkier; the commitment was made in part to curry favor with public-health officials who wanted Victory to survive and also to fend off competition from other hospitals.

  Victory became a major preoccupation for the senior staff, though most everyone else at the hospital was oblivious to the machinations involved. Like applying for Magnet status, trying to work out a deal with Victory was part of the hospital’s big ambition, regarded with admiration by some and as overreaching by others. For Naldi, who had to shoulder much of the burden of the Victory deal, it was worth the effort. “As long as they’re needed,” he qualified. “If they aren’t needed, they shouldn’t be there.”

  But need by whose measure? Did the community need another hospital or more assisted-living centers for an aging population? What about all those babies being born at Victory? Maimonides didn’t have room for their mothers or for them. What about turning Victory into a primary-care center, where inexpensive preventive medicine could be practiced, reducing overcrowding in emergency rooms all over the borough? I didn’t envy the Berger Commission as it worked out its assessment of waste and need.

  Both Maimonides and Victory were founded following the last great wave of immigration to the United States, in the nineteenth century. For Newman Dube, the founder of Israel Zion Hospital, which would become Maimonides, need was obvious, uncomplicated, and personal. Dube, born Nehemiah Dubovsky, came to America in 1888 from Minsk, at age twenty, because he was afraid of being conscripted into the Russian army. The Dube and Bashevkin families were part of the same chapter of U.S. history, in which impoverished greenhorn peddlers became prosperous American merchants. After the turn of the century, Dube moved his family to Borough Park, a fairly new community that had no hospital.

  Two incidents convinced Dube that the health-care situation in his neighborhood had to change. The first occurred in 1916, when Dube’s four-year-old son contracted croup diphtheria and barely survived the trip to the nearest hospital. The second incident, which took place almost three years later, was far more calamitous. The influenza pandemic of 1918, believed to have killed 20 to 24 million people worldwide and around 675,000 in the United States, found its way to the Dube home; the former peddler by then lived in a massive residence, with thirteen rooms to house him, his wife, and their six children. This time illness brought death. His fifteen-year-old daughter became part of the global statistic.

  Would a local hospital have made a difference? It’s doubtful, but Dube chose to believe so. Grief demands explanations. So just as Steven Cymbrowitz, a century later, would raise money for a cancer center in order to
give his wife’s early death some purpose, Dube the grieving father would became the primary force behind the creation of a hospital in Borough Park.

  The dedication of the hospital took place in 1919, which seemed—in 2005—like a comparatively simple time. The $10,000 Dube collected was adequate seed money for an entire hospital. In 2005 that $10,000 would be worth roughly $112,890, using the consumer price index as a comparison. In adjusted dollars it would pay salary and benefits for one registered nurse, or three or four defibrillators, or 220 emergency room visits (less than a day’s worth at Maimonides), or three bypass operations.

  But paying for health care was a problem even then. “By the early 1900s, the annual deficits incurred by most hospitals in New York City became a generally recognized problem among the city’s hospital trustees, administrators, and even charity workers,” wrote David Rosner in A Once Charitable Institution, a book full of reminders that hospitals have always struggled with finances, with management, with determining their social mandate.

  Was it ridiculous to try to connect this humble story of a father trying to cope with his daughter’s premature death to present-day Maimonides—the multicultural patient flow, the feuds, the political wrangling over Victory, the cancer center, insurance reimbursements—to Mr. Zen?

  Luckily—amazingly—I found a direct link, making me think that maybe it was true, min zhong zhu ding, “life is predestined.” One of Newman Dube’s children was still alive.

  Douglas Jablon introduced me to Daniel Dube, who was about to turn ninety-seven years old when I met him in his office at Park Surgical Company, across from Moishe’s Cleaners, under the elevated subway, a few blocks from the hospital. Park Surgical (named for Borough Park) sold all kinds of medical supplies, including wheelchairs, lactation aids, prosthetic legs, hearing aids. Newman Dube started the business in 1929, another legacy for his children and grandchildren, who seventy-six years later ran the business with their Uncle Daniel, the only living reminder of the past generations.