Rethinking the fundamentals

THURSDAY: Were the improvements taking root? Now everyone would know if the medical center's troubles were intractable or, just maybe, on the way out.

Donna Johnson wanted everyone to know that the food server on the 11th floor who hadn't been washing his hands was a "nice guy."

"A nice guy with dirty hands," Walerstein said. He was exasperated. A few people chuckled.

Clutching a microphone at the front of the hospital auditorium, he presided over the regular 7:30 Thursday morning meeting on patient care and quality. The discussion quickly focused on the imperative to imprint The Joint Commission standards on the hospital staff.

Those requirements could seem maddeningly picky and difficult to interpret. Johnson, a nurse in risk management, told the group one of the food servers didn't know that he had to wash hands between patients when delivering meal trays. Reducing infections by simple hand-washing is a goal at hospitals nationwide.

Nobody questioned that the dietary aide on 11 needed some help. But questions arose about an additional Joint Commission guideline that servers rewash their hands in the room if they happened to touch anything other than the meal tray.

Maria Ninivaggi, the hospital's head of infection control, said the guideline was "bordering on the bizarre" if aides were required to wash if they moved "a bottle or something."

"We have a consultant here," she said motioning to Kurt Patton, sitting several rows ahead of her. "Do you want to argue with my position?"

"Unfortunately, yes," Patton replied. Everyone laughed.

"Unfortunately," he continued, "The Joint Commission rocket scientists have said that if you touch a patient's inanimate objects, if the food server has to move the items around, the same rule applies."

As the meeting ended, 15 people peeled off and headed for the war room. A long table there held computers back-to-back that had been hauled in temporarily, and taped to a glass wall was an organizational chart with 14 different colored circles connected by a web of crisscrossing lines.

"Any global issues?" asked Maureen Shannon, vice president for quality management. She was in charge of the war room.

"I have a global issue: interpreting or translating," said Helen Lavas, director of service excellence. She had heard the hospital was doing away with consent forms in Spanish, a violation of federal and state civil rights regulations.

Lavas said that the hospital must provide documents in another language if 1 percent of the hospital's patient population spoke it as its first language. Close to 31 percent of NUMC's inpatients and about 80 percent of patients who go to its five community health centers are Hispanic, though they make up about 12 percent of Nassau's population.

Shannon agreed that NUMC couldn't just do away with the Spanish version of the forms. And, of course, there was The Joint Commission to consider.

"The Joint is not going to override the state or the [federal] Office of Civil Rights," Shannon said. "So I don't know if this was urban legend that we were doing this." It was a legend, and the Spanish forms would continue to be available.

At the end, Shannon announced there would be no meeting on Friday. But she wanted to know what they thought about the war room's work over the course of its first four days.

"Useful, do you think?" Shannon asked.

"They get the concept," said Glenda Thomas, nurse manager on the fifth floor.

She spoke about the growing number of staff asking her questions about Joint Commission compliance. "There's starting to be a long line," she said.

Again, everyone laughed.

Lesson learned Moments later, Thomas and another veteran nurse who had been at the war room meeting, Linda Donnelly, stepped out of the elevator onto the fifth floor.

It was 9:30 a.m. As these things go, it was a moment of truth.

Two days earlier, Donnelly, a nurse in quality management with 13 years on the NUMC staff, had been a tracer on the fifth floor - physical medicine and rehabilitation, Thomas' floor. The mock survey had uncovered a number of problems. Now Donnelly was back to see if they had been fixed.

In her last visit, she had found medication carts with broken electronic locks, a missing thermometer in a refrigerator and an expired blood culture tube in the supply room. Also, a doctor hadn't signed and dated charts properly.

Thomas was proud of her nurses and anxious, hovering next to Donnelly as she made her rounds. Donnelly found new keys had been made for the medication carts, a new thermometer had been installed in the refrigerator and all supplies were up to date.

"Now everybody knows, and they are doing the right thing," Thomas said with satisfaction.

Donnelly then asked for two random patient charts. She flipped through them slowly. Several minutes passed. Then she turned to Thomas.

"Only one problem so far and that is the team conference [meeting] didn't have a time. On those two charts, there are maybe 20 entries, so 19 out of 20 isn't bad. Overall they did very well."

Thomas left, smiling. As Donnelly sat for a moment at the nurses station, she said that when she first started doing tracers in July, her findings "would fill up two pages."

This mock survey showed genuine progress, she said. She said the hospital was improving because staff wanted the place to be better. "There's a huge buy-in," she said.

Before Arthur Gianelli became chief executive, Donnelly said she was embarrassed to tell people she worked at NUMC and would never think of seeing a doctor there.

"That has changed," she said.

Now, she said as she rose to go the elevator, she uses the hospital when she needs medical care herself.

Older than her years Stephanie Hernandez asked her mother, Thelma Garcia, to leave the room.

The nurse was carefully changing the towel-like dressing covering the burn on her neck and chest, and the girl wanted to spare her mother the pain of seeing her wound. "I don't want you to cry," Stephanie said.

Earlier in the week, Dr. Shabneet Hira-Brar, one of two psychiatrists who act as consultants for the medical staff, had visited with the girl. Her colleague, Dr. Damir Huremovic, who is from Bosnia, said Stephanie, the eldest child of immigrants, was culturally older than her years and took on a "mother role." Although she was worried about being scarred, she also took pains to make sure that people knew she did not blame her father.

Now, at midmorning, Garcia stood, hands behind her back, leaning against the wall in the hallway on the sixth-floor burn center.

Stephanie had a fever, and until it was gone for 24 hours, she had to stay in the hospital. Garcia confessed she wasn't sure she could take care of Stephanie's wound until it had healed more. And, the mother said, Stephanie "was a little sad."

But a few moments had brightened her stay in the hospital. The day before, Garcia had called Stephanie's best friend and the pair had spent all afternoon walking the halls.

And, Garcia said, when a chaplain, the Rev. Cletus Nwaogwugwu, who visited almost every day, went to make the sign of the cross, Stephanie asked him to make a cross on her head and on her chest and to pray for her. The Nigerian-born priest, who speaks fluent Spanish, had laughed. Then she asked him to touch her burn to help cure her.

As he was leaving, he promised, "I'll come back tomorrow. May God be with you."

"And with you also," Stephanie said.

Finally, time to go A few doors down and an hour and a half later, the mood also was anxious, but leavened with excitement. Rene Castro, the man whose foot had been burned when he was struck by lightning, was getting ready to go home after 12 days.

Castro grimaced as Robert Hughes, his physical therapist, helped him put on his sneaker. His sister-in-law, Teresa Castro, and niece, Erika, had come to take him back to his Hempstead home.

Castro said he was eager to go, and he sighed when he recalled the three operations to fix his foot. He said the hospital was helping him obtain insurance to cover his bills. He worried he might not qualify for any insurance.

"I may have to pay," he said through an interpreter. "If I don't qualify, I'll make arrangements to pay little by little."

A wheelchair nosed into the room, pushed by patient care assistant Wentworth Mullings.

"The limousine is ready," Mullings said with mock solemnity. "I am the chauffeur."

With that, Castro maneuvered himself into the chair and was wheeled into the elevator.

What are their chances? Kurt Patton, hired for three days as a consultant for The Joint Commission inspection, was going through his list of things that needed fixing.

"On the seventh floor, we did see consents [consent forms] without physician signatures," he said. Some doctors' notes appeared to be filled out incorrectly. "We saw one pre-anesthesia assessment with a post-anesthesia note, and that's kind of interesting."

It was 3:10 p.m., and this was his exit interview in the executive conference room before Walerstein, Shannon and Ninivaggi, among others. He had listed a range of problems, including: a dirty wall in the pharmacy, a suicide risk assessment form that was out of date, a lack of privacy in the psychiatric emergency department and some confusion by the staff about how patients lodge complaints about their care.

Ninivaggi said she was frustrated about a recommendation that multidose vials that have been opened must be discarded after 28 days.

She demanded to know the science behind it.

"Where are the outbreaks [of infectious disease] in the scientific data?" she asked him.

"None, none that I could point to," Patton said.

"Please, I am not trying to be disrespectful," she said. "People are being asked to do more and more with less and less. I don't see the science behind it. I see that it's a huge imposition that's being put on the staff that I don't see a rationale for."

Patton was implacable. "You're correct," he said, and he pointed out that it is the norm to discard the vials. "Unfortunately the perception of The Joint Commission surveyors is, that is what we expect to see in all hospitals, and we do see it in all hospitals."

Walerstein had broader concerns. He needed to know if the hospital had a chance to nail the survey or would it once again be a struggle. He decided to pop the big question: "What would your overall gestalt be of our Joint Commission readiness?"

"Actually, pretty good," Patton replied. "You get a sense of confidence in talking with the staff. They know what they're talking about; they know what they're doing. They seem very aware of the standards."

Walerstein nodded happily and afterward bounded into the elevator. He punched the button for the 11th floor.

"Sometimes you have to turn around to realize you've come a long ways," he said. The elevator doors closed. He couldn't predict what would happen when the accreditation team arrived - "sometimes you get a hard-ass team" - but he said the staff was "beginning to understand that we need to do to hardwire [Joint Commission standards] into the culture."

But if NUMC gets more than 12 citations from the commission, that would mean a "conditional" status, which would involve an appeals process to get full accreditation. "Obviously I don't want that. I want to clear it first shot."

The elevator doors opened, and he got off.

He was about to ask patients what they thought of his hospital.

Patients speak up At 3:55 p.m. Walerstein arrived on the 11th floor and strolled unannounced into James Spagnoli's room.

He and Lavas, director of service excellence, said they randomly visited patients once or twice a week. NUMC routinely asked patients to fill out questionnaires on their hospital experience - the topics ranged from the food to the friendliness of the nurses - and The Joint Commission would review those results during its inspection. But Walerstein liked to get his own feel for things.

He introduced himself to Spagnoli and his wife, Dolores, both from Uniondale. "What's your experience been in the hospital?" he asked. Spagnoli, 76 and frail-looking, was being monitored because he had shortness of breath and atrial fibrillation - an abnormal heart rhythm.

"Everything is very positive," Spagnoli said. He spoke with surprising vigor. "I always get upset when the hospital gets all this negative publicity."

Another man down the hall, who did not want to be identified, said that his care had been "excellent." But he said he had called three times to get the television turned on. Walerstein said he would check on it.

On the ninth floor, Lynette Cunningham, 51, of Uniondale, remained silent, looking straight ahead, when Walerstein spoke to another patient.

As he was about to go, Walerstein paused and asked her if there was anything he could do for her.

In a whisper, she said she would like some more chocolate pudding.

"We will do our best to get you some chocolate pudding," he said.

A half-hour later on the first floor, Walerstein and Lavas parted outside the elevator. Lavas headed for the kitchen. She said she was going to check on the pudding.

As she walked away, Walerstein called: "Could you look into the TV, too?"