The first person to greet me when I walked in the front door of Holy Family Hospital was Sister Marion.
"Can I help you?"
"Yes, Sister, I'm a CNA (certified nursing assistant) looking for work while I go through nursing school."
"I'll take you to the director of nursing."
Then Sister Marion disappeared.
I was to learn later that this encounter fit with her MO: ubiquitous and effective. Hold the pleasantries.
Like many in her era, Sister Marion ran the hospital with an iron hand. She started early making her rounds, scattering nurses from their nest at the nurses station -- chatting and filling out forms. Sister Marion had little tolerance for forms, lawyers, business managers... even, at times, doctors. Nurses belonged in the rooms, giving patients bed baths before breakfast. She was in the ER for every arrival. God help the drug seeker. At bedtime she washed the feet of diabetics and clipped their nails -- usually a podiatrist's chore since a skin break on a diabetic's foot could take months to heal, their circulation was so poor. She had been trained in this skill.
Now, meet the new boss: floating in on the high tide of the Medicare cash flow, professional "CEOs" with echelons of vice-presidents, managers, administrative assistants, and supervisors run top-down administrations aimed at the bottom line. The Sisters have gone on to their heavenly reward, and, unlike the dear Sisters, the new team keeps bankers' hours. Count the cars at the parking lot of your hospital on Sunday night at midnight. What you will see are the vehicles of essential bedside staff. Come back at 9:00 a.m. Monday and count the cars. You're in for a surprise: the multiple will be not two or three, as you might expect, but an exponent of 15.
On a slow Labor Day weekend I took my lunch hour in a walkabout through the halls and labyrinthine by-ways, down noiseless corridors and into untrafficked cul de sacs of a New Mexico community hospital. Closed door after closed door stood sentinel to their absentee owners: apparatchiks with such bailiwicks as: "Dedicated Preregistration and Verification," "Prevention and Outreach," "Performance and Improvement," "Vice President of Corporate Compliance," "Corporate Compliance Coordinator," "Decision Support Analysis," "Medical Benefits Evaluator," "Accreditation Coordinator," "Patient Safety Officer," "Organizational Effectiveness and Excellence," and my own personal favorite, "Denial Management."
Here is an average community hospital -- less than 200 beds -- with a command and control superstructure of a 2,000-bed midtown Manhattan Medical Center.
The new administrators, dressed for success, are skilled in extracting, mining and refining, gold from the mother lode of Medicare. Medicare, in turn, is devoted to process and protocols. Did you follow procedure? Was every "i" dotted and every "t" crossed? Did the proper forms get filled out? Keep the customer -- the Center for Medicare Services -- satisfied.
Patient outcomes have been superseded by paperwork. The new computer revolution now institutionalizes this fixation electronically. Patient care gets lost in the shuffle, often competing head to head with the bureaucratic demands. As a nurse, should I answer the call light or finish the form? Correct answer (if you are interested in job security): finish the form.
Meanwhile, nearly 1 in 5 patients returns within a month for treatment of the same illness... and a second billable cycle. In the trade this is called "readmission." In response to reformers like Dr. Ezekiel Emanuel and others, Medicare is now giving lip service to addressing this shameful, and very expensive, situation. Certainly Walmart, Home Depot, or Costco would stop everything, go into a corporate huddle, and come up with answers within the week if their rate of returns was 20 percent. In the case of hospitals, I can tell you in advance what their solution of choice will be: more forms to justify billing for ineffective treatments.
At the very same New Mexico hospital mentioned above, the in-house intranet used to -- probably still does -- have a tab, "FORMS." The tabs opens a list, in alphabetical order, of 1,400 of them. You didn't misread: 1,400 forms, at a hometown hospital.
In her day, Sister Marion would have chased money changers out of the temple.
May her soul, and the souls of all the faithful departed, rest in peace.
Amen.
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