The lights came on. Did we have any questions? Comments?
I spoke up. The drawings were beautiful, yes, thank you, but … Had they ever toured the existing hospital? Met with any of our patients? Discussed with them what they liked and didn’t like about their current living conditions?
They had not, no, not yet.
Would they like a tour? Sometime? At their convenience?
Yes, of course. They would give me a call when they had a chance.
The architects did give me a call, and I did take them on the tour. I introduced them to patients and nurses, and showed them the open wards, the open hall for playing poker, the church, the breezeways, and the stairwells.
They were intrigued, if a little stunned. As we walked around, they seemed to retract into their charcoal jackets, and though they didn’t touch anything, they made sure to wash up after we finished.
I didn’t expect much from them. I knew they had a thousand regulations to follow, a hundred people to satisfy, but I did hope they would take to heart the idea of making the new hospital as pluripotential as the old, where patient rooms could become offices when needed or where, in a pinch, we could store wheelchairs in a solarium when sunning had gone out of fashion. Who knew what medicine would be like, I told them, what fads might come and go in the hundred years their buildings would stand. The principle of privacy giving way to company? Style to comfort? Aesthetics to sturdiness? Could they try to build a place that, like the old hospital, would go with the punches, change with the tides of thought?
They smiled and nodded, but did not seem convinced.
When they made their next presentation, at the first of our newly instituted Town Hall Meetings, I made sure to go.
The presentation was almost the same as the one they’d shown the medical staff months before. Once again I saw the gardens and grounds, the lobby and the grill, although this time their rendering of the patients’ buildings was more detailed. On every floor there would be two “neighborhoods”—the new term for ward—of thirty patients each; in the center of each neighborhood would be an open nursing station, around which the fifteen double-bedded patient rooms would fan. Each patient room would have two flat-screen televisions and, perhaps, cameras, to allow distant family to see their dear ones without having to visit. Each neighborhood would have its own kitchen, where patients could cook, and its own common room, where patients could mingle. All the floors would be carpeted to help with the noise, and there would be a computer-adjusted air-flow system so that each kitchen, common room, and patient room would have its own closed environment.
A stir of unease went through the Town. We were used to something simpler, more open, and more neighborly than the architects’ neighborhoods, if neighborly meant running next door for a cup of coffee, a missing form, or just to chat. Still it wasn’t the computerized air flow, the carpets (a bad idea), or even the overall design of the buildings—stacked up, one identical floor on top of the next, with elevators the only access to fresh air—that made everyone worry. It was the wheelchairs.
Now everyone knew that the architects had spent a lot of time designing and that it was not easy for them to keep within their budget. Laguna Honda was, after all, a public hospital, at best nonprofit and usually antiprofit; our budget was fixed; and there were many regulations. A hospital had to have computerized air flow, we knew; the patients had to be in semiprivate rooms; there had to be so many bathrooms, elevators, sprinklers per patient; and the architects had to follow every rule. It was just that they forgot the wheelchairs.
“Are there any questions?” the head architect asked after he finished his presentation.
The audience was quiet. Then one of the nurses raised her hand. It was Christina.
“Where is the room for the wheelchairs?” she asked.
The architect looked blank. “Wheelchairs?”
“Yes. The wheelchairs for the patients. They have to be stored someplace. When they’re not being used, or at night; and the electric wheelchairs have to be charged.”
“Oh, well,” he mumbled. “How many are there? One or two?”
“Well, how many beds are there?” Christina asked.
“Sixty on each floor.”
“Well, then, sixty wheelchairs.”
That’s a lot of wheelchairs. They take up a lot of room. In the old hospital they were stored in various places, depending on the ward and its kind of patients. Sometimes in the unused kitchen; sometimes in the big room with the ice machine; most often in the solarium. Because when the old Laguna Honda was designed, wheelchairs were rare, but a belief in the value of sun and fresh air was common. A large solarium for taking the sun was put at the end of every ward and bedbound patients were wheeled into it daily so they, too, could get sun and fresh air. Later, after the sun fell out of fashion, the solarium was used for whatever was needed—as a bingo room, an isolation room, a room for making private phone calls, but especially for storing wheelchairs.
I wish I could say that the architects thanked Christina for her observation and incorporated it into their plans. But they did not. I’m sure there was a reason; still, to this day there is no special room for the wheelchairs in the new health-care and rehabilitation facility, and little enough space in the new patient rooms, and we don’t know what to do with them.
Meanwhile, the conflict between Dr. Stein and us was escalating.
Although at the board of supervisors meeting he had agreed to revert to our former admissions policy, whereby the doctors would decide which patients we could safely take care of, Dr. Stein did not reinstate that policy. How could he? His budget was no better than it had been before the board meeting, and there were more demands on it every month. He still had no place to send the unreimbursed psychiatric patients who lived at the mental health rehabilitation facility or the homeless psychiatric patients at the County, and there were more and more days when the County Hospital was full and closed to new admissions. On those days, the private hospitals had to admit the County patients, and this was bad for their budgets. It was usually bad for the patients, too, because the private hospitals were far away from their homes and stoops, had no records of their care, and discharged them as soon as possible. It was good for Dr. Stein’s budget because he didn’t have to reimburse the private hospitals, but still, it wasn’t a long-term solution.
And when he looked across town, what did he see? He saw Laguna Honda, with its 1,100 beds, its doctors and nurses, and its patients, most of whom, according to Targeted Case Management, could be discharged. Dr. Stein couldn’t help but think that this was the best place to send those patients at the MHRF and the County. So instead of going back to the old admissions policy, he started his “Flow Project.”
He called it the Flow Project because it was going to increase the flow of patients from the County to Laguna Honda by acting as a substitute for our admissions committee. He handpicked its members, and the idea was that it would pass along its preaccepted patients for Dr. Romero to rubber-stamp. To ensure its success, Dr. Stein replaced our executive administrator with a friend of his, Mr. James Conley. It was a big promotion for Mr. Conley, whose training had been in marine engineering.
Dr. Stein came over to the hospital to introduce Mr. Conley. Mr. Conley would preside over Laguna Honda’s evolution from the outmoded “model of medical care” to a new, modern “model of social rehabilitation,” he told us.
“What does that mean?” someone from the audience asked. “What is ‘social rehabilitation’?”
It meant, Dr. Stein replied, that at the new facility, three hundred beds would be reserved for homeless psychiatric patients.
Now, most of the staff didn’t care which patients we admitted as long as we had the resources to take care of them safely. But for some, the idea of the hospital becoming, even in part, a locked psychiatric facility was unacceptable. There were few enough places in the city for the elderly and disabled; and if three hundred beds were given to the homeless, what would
happen to the citizens who’d supported Laguna Honda over the years when they needed its services?
It especially bothered Sister Miriam, our resident nun. She contacted the newspapers with her concerns, and she made an appointment to see Mr. Conley as soon as he’d settled in.
The meeting did not go well. Sister Miriam began her speech with nunlike modesty, but pretty soon her Irish got the best of her. She raised her voice, and then she lost her temper. We have a moral obligation to care for our elders, she told Mr. Conley. If he put younger able-bodied patients in with elderly disabled patients, neither would receive the care they deserved! It was wrong! It was unjust!
But Mr. Conley was Irish, too. He listened, and then he interrupted. To the contrary, he said, the hospital had to help the County out during difficult budget times—everyone had to do their best. Sister Miriam was a member of the staff; she had no right to involve the media in Laguna Honda’s affairs. It would be better for her and for the hospital if she just piped down.
That was the wrong thing to say to Sister Miriam. She left his office and immediately contacted the community of well-connected professionals around the hospital. They were startled to learn about the new plans to turn the genial old almshouse into a psychiatric facility for the homeless. Then she met with the newspapers; with Dr. Romero, Dr. Kay, and Miss Lester. Last she met with the mayor, who agreed with her that moving the psychiatrically disabled homeless to Laguna Honda was a bad idea. He ordered Dr. Stein to revert to the old admissions policy and to stop the Flow Project.
So Dr. Stein changed his strategy.
Its first prong was Mirene Larose.
The position of director of nursing having been involuntarily vacated by Ellen Mary Flanders, Dr. Stein appointed Mirene Larose, RN, MS, CNS, as our new director of nursing. She’d been a nurse at the Mental Health Rehabilitation Facility and was in favor of turning a large part of Laguna Honda into a similar social rehabilitation facility. In fact, she had a grant proposal already to hand that proposed using the BioPsychoSocialSpiritual model for the rehabilitation of the psychiatrically disabled, drug-abusing homeless. Dr. Stein was delighted to let her try out her model on two wards at Laguna Honda, with a view to expanding it to all thirty-eight of our wards.
The second prong was hiring a health-care consulting firm, Health Management Associates, to advise him on the appropriate use of Laguna Honda. It spent months at the hospital, the County, and the community clinics, and its report was brilliant.
The city provided remarkable health care to its citizens, it acknowledged; the main problem being that there was no continuum of care. The County Hospital was separate from Laguna Honda Hospital, and the community clinics separate from both. All three had distinct administrations, clinics, and staff, and Dr. Stein was preoccupied with their operations. So its first recommendation was that he should hire a Chief Operating Officer.
Second, Laguna Honda was too big. It was old-fashioned to have such a large institution. Instead of going ahead with the rebuild, Dr. Stein should downsize the new facility by one-third and use the savings to provide long-term care in the community. If the city did need more long-term-care beds, he should contract them out to private hospitals.
Last was the problem of the unreimbursed patients at the mental health rehabilitation facility, for which Health Management Associates had a solution. The reason that the city did not receive payment for those patients was that the mental health rehabilitation facility was licensed as an institution for mental disease, and Medicaid only paid for the first two weeks of hospitalization for patients in an institution for mental disease. Laguna Honda, on the other hand, was licensed as a long-term-care facility and did get paid for psychiatric patients with medical problems. Dr. Stein had been prevented from transferring patients to Laguna Honda from the MHRF, true. But if he simply merged the mental health rehabilitation facility under Laguna Honda’s license, then its patients would, ipso facto, become Laguna Honda’s patients. So Laguna Honda could bill for them, and Medicaid would pay for them. Then, once the new Laguna Honda was completed, Dr. Stein could put it under the County Hospital’s license and the resulting “continuum of care” would not only allow for payment for its patients, but also put him in charge of admissions and the Laguna Honda medical staff.
It was brilliant, and Dr. Stein immediately began planning how to put it into effect.
A few weeks later, a new political committee appeared: Citizens for Laguna Honda. Its founders were Sister Miriam and Miss Lester, and its goal was to reserve the hospital for the elderly and disabled, not for psychiatric patients. The committee set to work to put an initiative on the ballot and slowly gained steam and money.
Then Dr. Stein had a setback. For the first time in its history, Laguna Honda failed its recertification as a hospital. It didn’t just fail; it was humiliated, if an institution can be humiliated, by the 274-page report of the State Licensing Bureau.
Every year the state came to the hospital to recertify it. But until Miss Lester retired, it hadn’t found much to dislike about the place except for our open wards. After she retired, it did begin to find many problems, however, all related to the budget cuts that Dr. Stein was making: the halving of the head nurses, the decrease in staff, the deferred maintenance of the buildings. But that year its report was scathing, although patience was required because, like all the investigative reports I’ve ever read, it lumped together the irrelevant with the shocking, the inevitable with the unacceptable, the nuisances with the catastrophes, and it started with the trivial.
Laguna Honda did not deliver mail on Saturdays, it began, in violation of Federal Regulation F170. The daily menus were not translated into Chinese, and this violated Federal Regulation F242. An open bottle of disinfectant had been found in a kitchen refrigerator (F252), and three pairs of slippers on the floor of ward D3 (F253). Next, there were problems with maintenance. Paint was peeling from the walls of ward E4 (F253); microwave ovens were not clean (F371); there were dusty vents in the bathrooms and mildew in the shower stalls. So for the first one hundred pages the report read like the report of a picky, shortsighted mother-in-law in white gloves, come to your big, rambling farmhouse to inspect. She would never want to leave.
You had to wait until page 100 for the real disasters to appear. The investigators had found alcohol and drug abuse at the hospital; unsafe sex between patients; even the selling of drugs. Patients had started fires; fought with each other; gang members had shown up and threatened and attacked patients. Many patients had decompensated, going back and forth between Laguna Honda and the County Hospital’s psychiatric department. Patients had fallen, and their call lights had gone unanswered; bedsores had developed. Although the investigators acknowledged that the staff was doing its best, they were also clear that the hospital had accepted patients it could not manage, was not being well maintained, and had insufficient staff. Until administration resolved all these problems, it concluded, the hospital would be fined one thousand dollars per day, and would not be reimbursed for new patients.
It was a pretty devastating report. And it begs the question: Why? Why couldn’t the hospital prevent falls and bedsores and keep the microwaves, gurneys, and windows clean?
There were reasons the hospital could not, but the usual culprit, the budget, was not really one of them, because the budget had never been cut. It had gone up each year, even as the number of patients decreased, and the staff-to-patient ratio was now higher than ever. The problem was that this additional staff was all administrative, hired to produce the assessments, policies, and procedures the Department of Justice and HCFA demanded. And, unlike Miss Lester, who toured each ward daily with set mouth and eagle eye, none of the administrative staff ever toured the wards. But without that scrutiny, all the plans, policies, and procedures didn’t clean any gurneys, turn any patients, or pick up any slippers off the floor.
What about alcohol and drug abuse, unprotected sex, fights and fires; why were they so difficult to prevent?
There were reasons, but again, not the budget.
First was our almshouse architecture—our hidden hallways, stairwells, and linen closets. There were just too many places where patients could go to do whatever they wanted to do. Although the architecture wasn’t the only reason. When the nuns ran the almshouses, there were incidents involving sex, drugs, and alcohol, but if you were caught, something happened. You were thrown out of the almshouse, or if you were too sick, you were punished in some way—confined to your ward, your cigarettes taken away. As for thefts, fights, and fires, the nuns of the Hôtel-Dieu simply called the gendarmes, who took the ex-almshouse patient to prison.
Our city’s gendarmes used to do that, in the old days, but no longer. Our patients were too sick and would not have enough medical care in jail, the police almost always concluded. Patients, even those who committed a crime, were almost never arrested. Even Mr. Jax, who set the arson fire on D3, had been ordered back to Laguna Honda, and he would have been sent back, too, except that he disappeared.
Of course, the hospital did have a policy against drugs, sex, setting fires, and attacking other patients, which patients signed when they were admitted. But if they contravened the policy, there were few repercussions. They were too sick to be discharged. Instead, the nurse manager would formulate a “contract” for the patient to sign, such as: “I will not smoke with my oxygen on”; and a behavior plan, such as: “If I do smoke with my oxygen on, my cigarettes will be taken away for twenty-four hours.” And even that kind of contract, according to the state’s report, contravened regulations, and the hospital received a citation for that, too. Anyway, demented patients who smoked, drank, and set fires did not understand contracts or repercussions.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 25