Hospital

by Julie Salamon

  “Our successes are all tied together,” said Olendorf. “We want the institution to look good. We want her to look good. We want ourselves to look good. She’s so different. If I would run into her in a classroom or something, I wouldn’t seek her out to be my friend. You have to spend time getting to know her. If you just saw the quirkiness, if you just saw the behaviors, you wouldn’t get to the depth of her, that depth of caring. She’s very sensitive. She’s very, very mission-driven. She lives out her idea that people should not be underserved and that we should be taking care of them, that they should get what they need, whatever that means.”

  Brier was tired and uncertain and vulnerable, but damned if that tough cookie would let anyone see her as weak. When I stopped by her office for a debriefing the day after the budget meeting, she was determinedly insouciant.

  “I’m sick and tired of not having the first baby of the year,” she said, and she wasn’t kidding: The New Year’s baby guaranteed good PR. “Peter and I were in the labor and delivery room on New Year’s Eve. I said to one of the nurses, ‘I don’t get it,’” she continued. “We are the biggest deliverer of babies in the state. Where are those babies? She said to me, ‘I’ve been here every year on New Year’s Eve for thirty years, and we’ve never had the first one.’”

  Then, absently, Brier said, “Peter and I always go to labor and delivery on New Year’s Eve. We only missed that one year.”

  She rarely talked about the accident, mainly by inference, but it never went away, the chronic condition that flared up when other pressures came to bear.

  Brier, sitting behind her large, immaculate desk, raised a manicured finger. “I have a new plan,” she said dramatically. “The first baby for the Jewish New Year—we could do the Chinese New Year.”

  In case I missed the joke, she said, “We have to have some fun.”

  The telltale phrase lingered.

  We only missed that one year.

  When she met Peter Aschkenasy, she was closing in on fifty. They were introduced by a mutual friend. Brier’s marriage to Steven Brier was over, after almost thirty years. Aschkenasy was still married to his second wife, but that marriage, too, was nearing the end.

  Hospitals had been part of their romance. When they began to see each other, she took him to visit Bellevue. When Aschkenasy—a marathon runner—was hospitalized for hip surgery, he called Brier from the hospital to tell her he had a craving for ice cream. She was cooking Thanksgiving dinner but left her guests to take him dessert.

  Then followed the dates that often ended with midnight jaunts through hospital corridors. Aschkenasy, drawn to the chaotic excitement of restaurants and politics, the not-nine-to-five, was comfortable in the all-consuming hospital world. (Too comfortable, some people complained; there was a feeling among some on the senior staff that Brier relied too heavily on her husband’s opinions.)

  They were well into middle age, still energetic and ambitious, youthful enough to dream about making an imprint, old enough to think about legacy.

  We only missed that one year.

  Two and one half years had passed since the accident. Aschkenasy would be classified as an invalid if he would allow it. His right knee didn’t bend at all, and the left could move sixty degrees at most. He couldn’t put on his socks by himself.

  Aschkenasy was far more easygoing than his wife, but they shared a forceful desire to resume life as it had been. He had his car specially outfitted so he could drive. He worked every day, across the river in Manhattan. They figured out which movie theaters had handicapped seats that could accommodate not just his wheelchair but the leg that stuck out straight. They ate at restaurants they knew would have room for the chair.

  Aschkenasy was determined to bend his knees. In October they had visited an orthopedic specialist about a procedure called a quadricepsplasty that could increase the mobility of the knees but could also leave his legs too weak to support his body weight. “I am not risk-averse,” the doctor told them, “but there is not much to be gained, and the risks are great.”

  He recommended physical therapy, which wasn’t what Aschkenasy wanted to hear, though he followed instructions and bought a treadmill the next day. He remained fixated on finding a surgical remedy—a remedy, not a stopgap—so they continued to doctor-shop. In November they found an orthopedist who thought he could take out some of the extra bone that had grown in his right knee and the quadriceps area. In December, having looked at additional X-rays, the same doctor told them they would also need a plastic surgeon. The skin over Aschkenasy’s knee was very tight, and the surgeon worried there wasn’t enough skin to close the wound after he opened the leg and took out the extra bone. The plan was to add a large skin graft, called a free flap, over the knee at the same time the leg was opened up, so extra muscle and bone could be covered.

  The surgery was scheduled for February. Brier knew too much about hospitals and surgery to feel sanguine.

  She always tried to accompany her husband to doctor appointments. “You have to have someone with you to take notes, to ask questions, to hear,” she said. “Even if you take notes, it’s hard to focus. I hear so many patients say, ‘What did he say?’ when the doctor walks out of the room. That’s why hospitals are scary. For all the care organized around you, when you’re in the hospital bed, I won’t say you’re dead meat, but you’re really in a vulnerable position.”

  For Sheila Namm the budget cuts were just part of the ongoing disaster drill she prepared for every day. Namm’s title was “vice president, professional affairs,” a general description of her responsibilities as whip-cracker-in-chief. A nurse and an attorney, Namm was in charge of screwup prevention, officially known as organizational performance, risk management, medical staff peer review, regulatory affairs, bioethics, credentialing, JCAHO readiness, and claims management.

  A couple of days after the budget meeting, Namm told me what was on her mind now that the hospital had survived Joint Commission inspection. “Terrorism, bioterrorism, internal and external emergencies,” she said. “That gives you a flavor of the list of things that are going to consume us.”

  It had been Namm’s responsibility to implement the recommendations of the Institute for Medicine, an advisory group chartered by Congress to advise on scientific matters. In 1999 researchers for the Institute issued a report called “To Err Is Human,” containing the estimate that ninety-eight thousand people died each year in the United States because of preventable medical errors. Surgeons occasionally chopped off the wrong leg—or took out the wrong kidney (that had happened at Maimonides a few years back).

  The report also found that medical technology may be amazing, but patients were putting their fate in the often unwashed hands of doctors and nurses, who were like forgetful children when it came to basic rules of hygiene. In response, like hospitals all over the country, Maimonides began “hand hygiene observations”; between June 2003 and September 2005 the hospital went from a 69 percent compliance rate to 80 percent. Hardly perfect, but there was measurable improvement, though how depressing is it to think you have to have a management team and charts and graphs to get medical people to wash their hands in a hospital?

  Namm, who was approaching sixty, was a kind of institutional spy. She even altered her appearance regularly and dramatically, showing up with short hair one week, long hair the next, color always to be determined. Her wardrobe was equally unpredictable: business suits one day, cowboy boots and cowgirl skirts the next. Underneath the costumes were tattoos, not available for hospital viewing.

  The budget cuts took away an unfilled position in her department just as she was dealing with new pay-for-performance requirements for Medicare reimbursement. For the past eighteen months, the hospital had been submitting data to CMS (Centers for Medicare and Medicaid) related to the treatment of patients with certain conditions, including congestive heart failure and pneumonia. Beginning in 2007, CMS would be paying hospitals according to how they stacked up in comparison to one another, w
ith full reimbursement going to the best performers.

  Namm approved of the public report card, but now she had one less person to collect and sort the data. Her small office, just down the hall from McDougle’s, looked like a storage closet, jammed with piles of paper.

  The data collection forced the hospital to constantly reevaluate its procedures and practices. Maimonides often got high marks (but some low and many average) from organizations that rated hospitals, including the Niagara Health Quality Coalition, a nonprofit that evaluates New York State hospitals (www.myhealthfinder.com), and HealthGrades (www.healthgrades.com), the for-profit national rating company that offers paid membership services to hospitals.

  What did it really mean for a hospital to measure up? What was the bottom line?

  Atul Gawande, a surgeon and author who writes regularly for the New Yorker, wrote an article called “The Bell Curve” in December 2004, in which he discussed the question of grades for doctors. “It used to be assumed that differences among hospitals or doctors in a particular specialty were generally insignificant,” he wrote. “If you plotted a graph showing the results of all the centers treating cystic fibrosis—or any other disease, for that matter—people expected that the curve would look something like a shark fin, with most places clustered around the very best outcomes. But the evidence has begun to indicate otherwise. What you tend to find is a bell curve: a handful of teams with disturbingly poor outcomes for their patients, a handful with remarkably good results, and a great undistinguished middle.”

  He continued, “It is distressing for doctors to have to acknowledge the bell curve. It belies the promise that we make to patients who become seriously ill: that they can count on the medical system to give them their very best chance at life. It also contradicts the belief nearly all of us have that we are doing our job as well as it can be done. But evidence of the bell curve is starting to trickle out, to doctors and patients alike, and we are only beginning to find out what happens when it does.”

  Sam Kopel, the medical director at Maimonides, once said to me, “What are the right statistics to use for outcomes? You treat a patient for pneumonia, and they go home and have a horrible course. They get readmitted, but the patients survive, so the mortality figures don’t look that bad. Patients leave here with a lousy life, to nursing homes, with tubes, with trachs. There’s no way to measure that. Outcome measurements is the black hole.”

  He went on, “Some things are easy to measure. Death. That’s easy to measure. Readmissions. You have an electronic way of counting something and assume it’s a proxy for the real thing. But how much happiness are you producing? Who the bleep knows? Think about it. It is very, very hard to measure. How do you measure outcomes of hip replacements? Thank the Lord we are designed, however we got here, whether Lord Darwin or the Creator, that most things tend to fix themselves, and it takes a lot to really fuck someone up. Most things do get better.”

  But, as he knew too well, some things only got worse.

  Sharon Kopel had been admitted to the hospital the weekend before the budget meeting. No one expected her to go home.

  Steve Davidson, the chair of the emergency department, one of Sam Kopel’s closest friends, sat through the budget meeting unable to concentrate on the numbers. Hatzolah was on his mind. He was trying to piece together how, in the past few days, he had managed to simultaneously antagonize the Orthodox ambulance corps, his most important provider of patients, along with two of the most powerful people in the hospital, Douglas Jablon and the president herself. What had he been thinking?

  Later he told me he finally grasped the farcical nature of his situation that evening, when his thought processes were aided by a clarifying glass of scotch: Hatzolah didn’t work for him, he worked for Hatzolah.

  How had he missed this salient point until now?

  He confessed he regarded the Hatzolah volunteers as “whackers” (the nickname in some quarters for volunteer firemen or EMS technicians). “The guys from Hatzolahs are like volley whackers everywhere,” he said. “They’re enthusiasts about their thing. They’ve got a little bit of—I don’t mean this at all disparagingly, and I hope it doesn’t sound like I’m dissing them—but volunteers everywhere have the I-want-to-be-a-hero-complex thing.”

  As the scotch worked its magic, Davidson remembered his grandfather, a cutter in the garment industry. “He was a labor organizer. I knew about equity and legacy. I knew the community owns the hospital. I believe it in my bones. But that’s extraordinarily hard to live by day to day, in a very challenging environment where many a day you realize your aspirations for yourself are not being met by you. That is humbling.”

  Davidson would be well cast as a distracted, curmudgeonly, brilliant, arrogant, amusing (or irritating) academic; he once told me he had imagined himself in exactly that role. “At the end of the day, I wanted to play pontificating professor, puff my pipe, drink my tea, have a little less crazed existence, compete on the intellectual front, and get some of the recognition I perceived my old man got walking down Spruce Street by Pennsylvania Hospital [in Philadelphia], big fancy hospital. Everybody in the neighborhood knew my dad,” Davidson said. “He was in clinical practice, he did teach, he was on the faculty at the graduate school of medicine at the University of Pennsylvania until he died.”

  Davidson intended to become a research chemist but went to medical school, like his father. At heart he remained a data guy, not much on bedside manner, preferring to improve patient care through systems that built efficiency. Self-aware, though. “I’m not the smoothest, most sociable kind of fellow,” he said. “I can be a prickly, opinionated kind of character.” He went to Wharton Business School. He read studies of how Disney World used an engineering approach to help the park deliver fun more systematically and profitably. He read about combining management and medical measurement tools. For eleven years he was the medical director for the City of Philadelphia Emergency Medical Services System.

  In 1995 he got a call from a headhunter and went to New York to meet Stanley Brezenoff, who had then been at Maimonides all of four days. “I met Stanley at lunch, and within ten minutes I knew I could work for this guy,” recalled Davidson. “He said to me, ‘Steve, I’m here four days, and all I’ve heard is how terrible the ER is. The community, the medical staff, my administrators. Not only are my administrators telling me how terrible the ER is, they’re telling me how to fix it. If they know how to fix it, why is it so fucking terrible? We’re going to fix it, because it is so important to this community. ’”

  Davidson saw opportunity in Brezenoff’s determination. Hospitals had finally discovered W. Edwards Deming, the management guru, and his “continuous quality improvement” model, with emphasis on interdisciplinary teams. Japanese car companies started using it in the 1950s and 1960s and went on to lead the industry. Davidson wanted to try Deming’s methods at Maimonides.

  Davidson understood hypothetically what Brezenoff meant when he said that the ER was “so important to the community.” Davidson did not understand, however, that in the ER, Hatzolah was the community. Or rather, the Hatzolahs, plural: Borough Park, Flatbush, Williamsburg all had their own branches with their own leaders.

  “Stanley didn’t make it plain how much working with Hatzolah was my responsibility,” said Davidson. “He buffered that from me greatly. There were times he suggested I make more phone calls to them. I did. Stanley calculated correctly that my general motivation to make things better would deliver what they required, so he didn’t emphasize the courting of Hatzolah. If that had been said to me in February, March, May, of 1995 while I was negotiating, it would have been a turnoff, and I wouldn’t have taken the job, and that would have been a mistake.”

  In the ten years he’d been chief, emergency-room volume had increased almost 70 percent. In just the first year, without an increase in the budget but with rearrangement of shifts for doctors, nurses, and clerical staff, the number of ER admissions grew to 68,000 from 50,000. By 2005, the n
umber was 82,000.

  Davidson associated the increase in numbers to continuous quality improvement, the triumph of his systems, but the Hatzolah coordinators believed they controlled the switch. Davidson admitted he didn’t know how to concede the point, even a little.

  “I’m a logician,” said Davidson. “It’s my impression that when I talk about how we did it, people’s eyes glaze over. I used to enjoy going out to Hatzolah and these other community groups and watch Stan Brezenoff do these great spiels. It was admirable, and I’d be so envious. I just can’t do that shtick. I’m pretty proud of what we’ve accomplished, but the challenge I face right now is the expectation of comparable improvement. Well, I’ve squeezed the rag drier sooner. It’s getting a lot harder.”

  Barbara Sommer, a calming, eye-in-the-hurricane presence, longtime director of nursing for the emergency room, had been promoted the previous July and hadn’t been replaced. Her absence represented a double disappointment. For three years Sommer had been in charge of the hospital’s application to be accepted in the Magnet Recognition Program, developed by the ANCC, the credentialing branch of the American Nurses Association, to recognize health-care organizations that provide nursing excellence. Only 4 percent of health-care organizations achieve Magnet status, whose prestige was an invaluable attraction in an era of chronic nursing shortages. The application process is long and arduous, requiring volumes of documentation covering patient-satisfaction surveys, nursing research projects, and peer review. Once a hospital is part of the Magnet program, someone has to be in charge of maintaining the standards that got it there. Sommer was designated that person.

  Sondra Olendorf, head of operations, had cause for optimism when she promoted Sommer. The hospital’s lengthy narrative analysis was deemed sufficiently excellent by the ANCC to take Maimonides to the final round, a site visit. Eighty percent of the hospitals that get this far become part of the Magnet program. But once again Maimonides was relegated to almost-as-good-as. The hospital didn’t make the final cut. Now Sommer had a better title but no clearly defined job, and the emergency room didn’t have Sommer.