One step forward, two steps back

TUESDAY: The staff gets an earful after a patient and her infant wander off the premises. Medicine carts are found unlocked. So far, preparation for the inspection has uncovered problems big and small.

As Walerstein told it, county police detectives had brought a woman and her 3-month-old baby into the emergency department Friday night. As the baby was being examined, the staff became concerned the mother was depressed.

Walerstein stood in front of the hospital auditorium before 50 physician and nursing administrators at a twice-weekly 7:30 a.m. meeting on patient care and quality.

Doctors decided to send the baby's mother to the psychiatry department for evaluation. Instead, she walked out of the hospital with the baby. For three hours, no one at the hospital knew where she was. Nassau police issued a national Amber Alert.

"Happy ending, mom found, everything OK, CPS evaluated, said OK," Walerstein said.

His voice rose. He was lecturing now. "Maybe next time," he said, "we should all live through three hours of hell trying to figure out what the potential complications are and what the potential consequences are of us not following through."

The auditorium became pin-drop quiet. Even those checking their BlackBerrys looked up.

It was the day a consultant was to arrive to see whether the hospital was ready for The Joint Commission inspection. And tracking the whereabouts of patients such as the mother and her baby would definitely be part of the accreditation drill.

"We have to learn from these things before we have a real incident," Walerstein said. "Healthy organizations make mistakes; healthy organizations do not make the same mistake twice," he said.

Then he repeated: "Healthy organizations do not make the same mistake twice."

Mock surveys, designed to anticipate a Joint Commission inspection, already had uncovered a lot of problems. Narcotics boxes had been found not properly bolted to walls or inside refrigerators. People weren't putting blades in the biohazard boxes. A nurse manager stood up in the auditorium and attributed the failure of employees to lock the refrigerators to "the total disinterest of the staff."

"It's 'total disinterest of the staff'? 'Total disinterest of the staff' in narcotic safety?" Walerstein thundered. "Leadership is in this room, and it is our job to make them care or get rid of them."

If Walerstein was playing bad cop, chief executive Arthur Gianelli would now play motivational speaker. He bounded to the front of the room and took the microphone.

"I want to read this quote: 'Nobody trips over mountains. It's the small pebbles that cause you to stumble.' "

"This is about pebbles, isn't it?" Gianelli said. "Some of the pebbles are small. . . . When you talk about staff not caring, those are big pebbles, those are rocks. But at the end of the day we have to, one by one, clear the pebbles, clear the rocks, OK?"

Heads nodded, papers shuffled and people rose out of their seats. No one said much. Day 2 of the war was under way.

Plenty to fix A few minutes later, the elevator doors rattled open on the fifth floor, which houses physical medicine and rehabilitation. Out stepped a "tracer."

She was Linda Donnelly, a veteran NUMC nurse from quality management. Her job: make surprise visits to hospital departments, looking for faulty procedures, broken equipment or sloppy paperwork that might be detected by Joint Commission surveyors.

She soon found an unlocked medication cart near the nurses' station. Any medication must be locked at all times unless it is under close surveillance by a nurse or doctor. Donnelly was disappointed; this had been reported as a problem on other floors, and she had hoped that managers elsewhere would check to see if it was a problem on theirs, too.

She jotted on her clipboard. "Hi, I'm Linda from quality, and your cart is not locked," Donnelly announced to nurse manager Glenda Thomas. Thomas told Donnelly that the electronic locks for all five medication carts on the floor were broken.

Thomas said she thought that as long as the cart was under direct surveillance, it was OK if it were unlocked.

Donnelly spoke to Thomas in a low-key yet authoritative way. She said the cart was parked too far away from the nurses at their station to pass Joint Commission muster. Thomas, at the hospital since 1987, took the bad news with a small nod. She, like Donnelly, had been hand-picked to be part of the war room - a testament to her reputation as a hardworking nurse committed to good patient care.

But in the next hour Donnelly found other problems: Temperatures were not consistently logged in for the medical refrigerator, which was also missing its thermometer. A blood culture tube in the supply room had expired. And a review of two patient charts found that a doctor had used abbreviations on the narcotics administration sheet that could be misconstrued.

None was a major issue, but they could add up in the real Joint Commission survey: Walerstein had said getting 12 or fewer RFIs - requirements for improvement - hospitalwide means "you are out of trouble." Every one of these potential infractions counted.

Donnelly said she would be back in a few days to check on things and quietly headed toward the elevator.

Progress and worry At 10:45 a.m. on the sixth-floor burn center, Rene Castro looked remarkably happy for a man who a week earlier had been struck by lightning.

He said he still had pain at his left thigh where a strip of flesh had been lifted to graft onto his burned left foot. But the pain had diminished from the day before. This morning was the first time he had been able to sit in a chair, with his newly dressed foot propped up. Next to him, in the rumpled bed, lay his Bible. Castro said he kept it there to help his leg heal.

Dr. Aleksandr Shteynberg, one of his doctors, told Castro that he should be able to take his first steps tomorrow.

"I think everything is working good," Castro said. He smiled.

Two doors down, Thelma Garcia confessed she was worried about her daughter Stephanie, burned the previous Saturday.

Stephanie quietly watched cartoons. On her tray sat Froot Loops and apple juice, both untouched.

Her mother said that the day before friends had dropped by to visit.

But Stephanie had refused to see them.

The 9-year-old was embarrassed. She didn't want them to see her bandaged. Now Garcia wondered whether she should request a consultation with a psychologist.

Her eyes fixed on the television, Stephanie appeared not to hear a word her mother had said.

Meeting draws a crowd At 4:10 p.m., no empty chairs were to be found in the executive conference room. The Executive Committee of the Medical Staff was having its monthly meeting with Walerstein and Gianelli.

Before Gianelli became chief executive, the group was a rubber stamp, doing the administration's bidding without debate, said Dr. Lyn Weiss, chairwoman of the department of physical medicine and rehabilitation who had been elected to lead the executive committee. She has served on the committee since 1994.

Now, she said, it openly discussed issues. The past three years "have been the most exciting and energizing" since she had come to the hospital as an intern in 1985, Weiss said. "Patient care and quality are our first priorities," she said. "In the past we were struggling so financially."

But working more collaboratively meant the committee meetings had grown longer and longer.

This one promised to be a killer. The agenda ran to four pages.

After the minutes, a treasurer's report and other quick business, Walerstein took over. At the top of his 10-item list was preparation for The Joint Commission survey.

"I know you have heard about The Joint Commission, but you can't hear it enough," Walerstein began. It was, he reminded them, "war month."

With faces set and serious, no one in the room looked as though they doubted it for a minute.