Long the region's most troubled hospital, Nassau University Medical Center finally has a chance to leave its past behind.

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Long the region's most troubled hospital, Nassau University Medical Center finally has a chance to leave its past behind. 
Any day now, NUMC will undergo a surprise inspection by the national body that accredits hospitals. 
The stakes are extremely high. Nobody thinks NUMC will fail - that would mean losing millions in federal money - but simply passing the test is not enough for chief executive Arthur Gianelli. To turn the corner, NUMC has to ace it. 
For the past three years, Gianelli has been working to transform NUMC from a place known for treating victims of gunshots and car wrecks into a model community hospital. 
Not long ago, few people gave him much of a chance. 
The hospital struggled for decades in the gears of Nassau County politics. Politicians squeezed its budgets and cut its staff, and chief executives never lasted long. Experts cringed at the chaos - this was Nassau's only public safety-net hospital, with a stated mission to serve the poor. 
Fixing NUMC reflects the national drive to reform a health care system marked by high costs and uneven quality, a push that in part relies on hospitals meeting accreditation requirements. 
NUMC will be tested on 1,614 such standards, and Gianelli allowed Newsday unprecedented, behind-the-scenes access in August - "war month," they called it - as the staff was consumed with getting ready for the big inspection. 
Success hinges on whether the housekeeping staff properly disinfects the beds, doctors write their orders legibly, and food-service aides, between meal deliveries, remember to wash their hands. 
The question is, can they pull it off?

Long Island

Nassau

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Nassau hospital has chance to leave its past behind

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 <a href="/topics/Nassau">Nassau</a>'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?"

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Rethinking the fundamentals

Not everyone embraces the idea of a "safety net" hospital such as <a href="/topics/Nassau_University_Medical_Center">Nassau University Medical Center</a>. 
Some critics charge taxpayers should not pay for free health care to the uninsured and / or undocumented, especially given the difficulty more Americans have meeting the rising cost of insurance. 
Michael Cannon, director of health policy studies at the libertarian <a href="/topics/Cato_Institute">Cato Institute</a> in Washington, D.C., said providing free health care raises what he called "the Good Samaritan's dilemma": The more you give people, the less they rely on themselves. 
He said he favored private charity care, which he said is more cost-efficient than large government bureaucracies. 
People "get annoyed," said Patrick Nicolosi, president of the Elmont East End Civic Association. "They see that the people who are getting it [health care] for free are getting better services than those who have insurance." 
He said he believed stanching the flow of undocumented immigrants would help. 
Dr. David Gratzer, a practicing physician and senior fellow at the conservative Manhattan Institute, said he believed in "the concept of a safety net." 
But, he said, "we spend much on the safety net and don't get much in return." He favors turning over federal health-care dollars to the states to encourage more experimentation. "It's like welfare reform," he said. "There isn't one model."

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Critics make their case against 'safety net' hospital

WEDNESDAY: A paid consultant finds there's plenty of work to do. Stephanie Hernandez gets an important piece of news about her recovery, while Vicente Sobredo goes to the operating room. 
It was toward the day's end, around 5, when the tension in the conference room started to rise. The talk had turned, of all things, to the right way to disinfect a room after a patient clears out. 
Maureen Shannon, 54, a nurse who had risen to vice president for quality management, had gotten word that the housekeeping staff on the 11th floor wasn't waiting long enough for a disinfectant to work when they cleaned vacated patient beds. Some appeared to be waiting only two minutes when they should have been waiting 10. 
Shannon put the issue to Maria Ninivaggi, the head of infection control. Were they using the wrong disinfectant? 
"It may be that they could not be using what it is you wanted them to use," she said. 
Ninivaggi took a breath, then spoke deliberately: "I reviewed the labels of the manufacturers of the two germicide detergents we use," she said. "They both say 10 minutes. . . . They are taught 10 minutes." 
This was exactly the sort of detail that The Joint Commission would seize upon in the upcoming inspection. The Centers for Disease Control and Prevention estimates that health care-associated infections account for about 1.7 million infections and 99,000 deaths each year, making them one of the nation's 10 leading causes of death. In 2008, NUMC scored at the state average for such infections. 
Shannon said she had been told there were two products in use on the 11th floor. One required 10 minutes, and the other was a germicidal wipe used for two minutes. 
Ninivaggi looked perplexed. "But the germicidal wipe is not something that would be used on a bed." 
Shannon said she was told a housekeeper was using it on a bed. 
"Where?" Ninivaggi said. 
She was insistent. "Where? We don't do that. We don't do that. It is not allowed. I need to know who, when and where. How can we find out?" 
No one said a word, and Ninivaggi cooled down. 
"They need to know they can't make the bed up for 10 minutes," she continued. "They cannot make the bed up until it dries, and the dry time is 10 minutes." 
"So," said Shannon, "we have got to tell nurses, because on 11 they knew to wait until it was dry but they didn't know it was 10 minutes." 
Ninivaggi sighed, looked down and put her hands on top of her head. 
A delicate surgery Dr. John Layke, chief resident in plastic surgery, stood leaning over a monitor in a cavernous operating room. Glowing on the screen was a black-and-white CT scan of a shattered skull. 
Unconscious two feet away on the operating table was the patient, Vicente Sobredo, 72, a retired attorney from <a href="/topics/Uruguay">Uruguay</a> who a week earlier had fallen down the steps of his son's Levittown home. He broke two ribs, fractured his collar bone and cracked open his right temple. 
Middle-class patients such as the Sobredos are not the norm at NUMC, and they had been nervous about him being brought to a public hospital. About three-quarters of the hospital's patients either have no insurance or are on government-funded Medicaid or Medicare, according to NUMC. 
Pointing to the CT scan, Layke noted where some of the fracture above the right brow had buckled. "Here, it's broken out here," he said. 
Layke said the surgery would be "like repairing eggshells." 
Even as NUMC readied for the upcoming inspection, the staff had a lot of other everyday work to do. NUMC is known for its top-level trauma care, but it also offers a full range of medical and surgical services, though for some specialties such as radiology it relies on doctors from the <a href="/topics/North_Shore">North Shore</a>- <a href="/topics/Long_Island">Long Island</a> Jewish Health System. 
Plastic and reconstructive surgery, however, remains homegrown. The chairman of the department, Dr. Roger Simpson, said that NUMC, a teaching hospital with 155 medical students, is a hot spot for nearly 300 residents and fellows. Young doctors such as Layke can hone their skills handling the wide variety of cases in reconstructive and plastic surgery that come to a public hospital. Car wrecks. Household falls. But no tummy tucks - cosmetic surgery is not done at NUMC. 
"It has been an interesting week," said Layke, 34, as he walked over to put on his surgical gown. A few days earlier, he had operated on Rene Castro, the man who had been struck by lightning. They had taken a strip of skin from Castro's thigh and grafted it onto his burned foot. 
A little after 9 a.m. nurses helped Simpson and Layke into their gowns and painted Sobredo's face with the antiseptic Betadine. Then, in the standard precaution to ensure the right operation was being done on the right patient, a nurse called out, "This is Vicente Sobredo," and she described the operation. "All those in favor?" 
The two doctors and their eight-member team of nurses and technicians responded in unison: "Yes." 
To spare Sobredo more stitches and the possibility of another scar, they planned to go in through the cut from the fall above Sobredo's eye. Then, Layke said, they would lift the bones up to make them flush with the rest of the skull. Finally, they'd hold them in place with tiny plates and screws. 
Layke made the first incision while Simpson dabbed away blood. The two doctors' surgical masks muffled their words. 
"Where do you want to be?" Simpson said. He coached the younger man. "Let's open up this region." 
As if choreographed, a nurse smoothly lifted instruments arrayed on a tray and placed them in the doctors' waiting hands. As Layke cut, Simpson either dabbed or sutured. Theirs was a quiet ballet of hands and fingers. 
Steps to recovery His mouth set, Rene Castro steeled himself and gripped the crutches under his arms. 
Physical therapist Robert Hughes stayed close to Castro's side as he took his first steps down the hall of the sixth-floor burn center. It was 10:50 a.m. The doctors had told Castro he might leave the next day. 
"Make sure those crutches are out front," Hughes said. Castro carefully moved the crutches forward. Then he moved his heavily bandaged left foot, followed by his right. Castro paused, breathing heavily. "Good," Hughes said. 
After two or three steps, Hughes asked an aide to get Castro a chair and the sneaker for his unburned foot to replace the hospital sock he was wearing. When the chair was brought, Castro fell heavily into it. 
Meanwhile, two doors down, Stephanie Hernandez sat in bed staring at Barney on TV. Her mother, Thelma Garcia, was nearby. 
Stephanie had told her mother she was worried whether she'd be permanently scarred. She wasn't eating much, either. 
Both looked up when Dr. Louis Riina, the assistant director of the burn center, entered the room. In Spanish, Garcia explained her daughter's worries. Riina spoke a blend of American-accented Spanish and English. 
"Usually I give burns two weeks to heal," he said in English. "Usually if they heal within that time period, generally the incidence of scarring is very small, and that's my hope for her. No problema. She's just in medio [the middle]." 
But Stephanie said she didn't understand. 
"Which part don't you understand?" he asked. He perched in a chair next to the bed and looked directly at her. 
"All of it," she said in a small voice. 
He smiled and spoke gently. "You got a burn from what fell on your chest," he said. "You're healing really good. And the more you eat, the better you are going to heal and the nicer your skin is going to be. And you're right in the middle of your treatment." 
"My skin is coming back?" she asked. Hope crept into her voice. 
"Yes, and it's in the middle of coming back. You just have to be patient while you're healing. While you're healing, eat lots and lots of food because that's what brings your skin back, OK? 
"Does it help to know all the details?" he asked. 
She nodded. 
Surprised by care At 1:30 p.m. Simpson walked into the waiting area on the second floor. The Sobredos rose together to meet the plastic surgeon. 
"Everything went well," Simpson said. "He's going to be fine." 
In a darkened recovery room 40 minutes later, Sobredo's wife, Maria, and the rest of the family saw him lying in bed. Bandages covered his head. A nurse said he had been agitated but now was sleeping. His daughter-in-law, Andrea Sobredo, confessed that the family had been anxious about the care he might get at a public hospital. But she said NUMC had been stellar. She described the hospital's finance people, who helped the family access the grandfather's private insurance in <a href="/topics/Uruguay">Uruguay</a>, as "angels." 
Maria and Andrea hugged each other for a long time and said nothing. 
Insider's view The 18-foot-long, 9-foot-high hyperbaric chamber, painted baby blue, looks like a submarine. Its inch-and-a-half-thick steel hull is studded with portholes and laced with intricate piping. 
The chamber, pumped with 100 percent oxygen, is used to speed up wound healing or to treat divers who have the bends - decompression sickness caused when breathing nitrogen under pressure. At that moment three patients and a hyperbaric tech were inside. They call it "taking a dive." 
At 2:15 p.m., Kurt Patton walked in with barely a glance at the towering chamber. 
In a quiet and even voice, he asked to see three randomly selected patient charts. 
Patton, a consultant, had been hired for three days to appraise NUMC's readiness for The Joint Commission survey. He was on his second day, and his visits to various parts of the hospital were unannounced. He was one of several consultants hired to make sure NUMC administrators got a diverse range of advice. 
Patton, 57, was an insider. He was a pharmacist who had worked for the commission as executive director of accreditation services and for the state Office of Mental Health for many years. That day, he had already visited four other areas. In his travels, Patton has seen plenty of hospitals where the staff is interested chiefly in passing The Joint Commission "test." He said he was impressed with NUMC because "they are not dressing for a theatrical part; they want to change behaviors." 
Patton flipped through the hyperbaric chamber charts and asked for what was called the ambulatory summary list, a rundown of all of a patient's visits and treatments. 
Donna Hangan, a nurse in the hyperbaric, burn and wound clinic, said she didn't have that. 
Patton explained that it was designed to be a "snapshot summary" of care. 
"They'll be looking for that," said Patton. He meant The Joint Commission surveyors. 
"We have weekly staff meetings on Monday morning, and once a month we have full staff meetings," the nurse said. She looked flustered. "I'll bring it to the attention of the big staff meeting this Monday." 
Asked if she was worried about The Joint Commission survey, she said, "Now I'll be because there's a piece of information missing from our charts. But normally things are very much in order. But now, this paper is missing."

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Pushing to get better

The Joint Commission has not made its visit. But NUMC has maintained its vigilance. 
Maureen Shannon said she still regularly sends out nurses as "tracers" to do mock Joint Commission surveys, a practice Walerstein said he intends to continue after the commission comes. 
The hospital still routinely brings in consultants for an outsider's view. And Walerstein continues to hold his 7:30 a.m. meeting Tuesdays and Thursdays on quality issues for heads of staff. As a result, Walerstein believes many of the changes have been "hardwired" into the staff. "It's really been drilled in by the nursing administrators," he said. 
Walerstein cited one example: Recently, the hospital was recognized by the National Association of Public Hospitals for reducing by 25 percent the number of patients who got ventilator-assisted pneumonia from 2007 to 2008; in fact, for two months, no patients got the disease. 
Reducing these kinds of hospital-acquired infections is one of many Joint Commission goals. 
RENE CASTRO The <a href="/topics/Hempstead">Hempstead</a> carpenter hit by lightning has been back at work since January. He said he still feels some pain in his foot and the doctors have told him he may need another skin graft. He is also waiting to hear whether he qualifies for insurance. 
STEPHANIE HERNANDEZ The 9-year-old scalded on her neck was able to start third grade four weeks late at Smith Street School in <a href="/topics/Uniondale">Uniondale</a>. She had physical therapy for three months to help stretch her neck, though she said it still hurts "a teeny, little." She faces reconstructive surgery to reduce the scarring. 
VICENTE SOBREDO Daughter-in-law Andrea Sobredo said her family returned recently from visiting him in <a href="/topics/Uruguay">Uruguay</a>. He has no scar on his temple from his fall and was so hardy he was carrying his 12-year-old granddaughter piggyback, she said. He also took the "kamikaze run" at a local water park. "I said to him, 'If you break one bone, I'm not taking care of you,' " she said with a laugh.

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Keeping track of hospital's, patients' progress

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. <a href="/topics/Nassau">Nassau</a> 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.

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