When Hospital Leadership Fails

by Dan Walter

“High above Cayuga’s waters/There’s an awful smell/Some say it’s the water…”

Actually, it’s the executive suite at the local hospital.

The rug under which unpleasantries are swept appears to be getting lumpy at Cayuga Medical Center in Ithaca, New York, and chief executive John Rudd is taking action. A recent flurry of memos laid the groundwork for a new public relations campaign to reassure the public that everything is copacetic at CMC, and furthermore, all the indices a­re up.

The propaganda push is in response to a flair-up in a long-running and rapidly deteriorating labor situation, which began with some anonymous postings on a new website which I designed for just such a purpose. In August, shortly after the site was launched, I received reports of patients getting hurt at Cayuga and that two people had died because of management’s inability to get a handle on the staffing situation.

CMC executives say that the hospital is safe and that the reports are false, reassuring the community by citing an “A” rating for patient safety from an independent organization called The Leapfrog Group.

What they are not telling the community is that they got that “A” rating by not reporting damaging information, like the lack of safety training and leadership — and that hospital does not have enough qualified nurses. Nor do they have enough specially trained doctors in the ICU.

At least I’m assuming they lack those things, otherwise, they would have submitted the reports and really earned the rating. Why Leapfrog considers a shortage of experienced nurses and doctors to be no impediment to a perfect score, I don’t know.

CMC executives say the negative stories are nothing more than provocations being spread by a certain minority of disgruntled nurses who are agitating for a union.

The issues raised by workers at Cayuga are familiar to nurses across the country — mainly that hospitals generally do not hire enough nurses, that they do not pay enough to keep the best nurses, and that they don’t provide enough staff or moral support. The result is stressed, overworked front line caregivers and unsafe conditions. Cayuga workers say that in high-pressure units like intensive care and the emergency department, it is not uncommon for one nurse to be responsible for three — and sometimes four — critically ill patients at a time.

Management tries to fill the gaps by “floating” nurses from other departments or using travel nurses or newly graduated nurses. The problem is that these nurses are often thrown into the breach without the necessary skills or training, which makes things worse because somebody has to keep an eye on the bewildered and intimidated newcomers and show them how to do very specific things in life or death situations. On top of that, there never seems to be enough secretaries or other support staff to help the nurses do what needs to be done.

One CMC worker wrote that “a patient in the ICU died because a Levophed drip ran dry, and there were not enough nurses on the floor to hear the pump alarm. There were several critically ill people needing multiple nurses in the room to care for them, so when the pump ran dry in one patient’s room, no one heard it until the alarm on the monitor sounded — and by then it was too late. Both nurses and doctors took this patient’s death to hospital administration. At a critical care meeting, we brought up staffing issues and this event being in direct correlation to short staffing. It was swept under the rug and never addressed.”

The story got enough attention around Ithaca Commons to warrant a response in the form of a company-wide memo from Cayuga’s VP for Medical Affairs, Dr. David Evelyn. Evelyn, who pulls down in excess of $350,000 a year in service to the non-profit community hospital, says no such thing ever happened — “based the information we have.”

Evelyn reminded workers that there’s no need to be talking out of turn, to be disloyal and make the institution look bad. CMC has an Incident Reporting System and there are Safety Huddles and sometimes there’s even a Root Cause Analysis. “If our actions cause serious harm to a patient,” Evelyn wrote, “we would self-report it to the New York State Department of Health.”

Of course they would. But then again, define serious.

Then there was the ER nurse struggling to care for four desperately sick patients at once. “Two were critically ill and intubated, headed to the ICU. One was stable and the other was actively dying and in need of comfort and pain control.” Each of the other four nurses on duty was also dealing with four critically ill patients, sometimes five. “The nurse with the critically ill patients and the dying patient had to make a determination of whether to comfort and relieve the pain of an elderly dying man or save the patient that was intubated on multiple IV’s and life-sustaining meds. The elderly man died a painful death, alone. With more staff, he could have had pain control and someone with him.”

Again, workers say, the administration was made aware of the situation, and no action was taken.

Again, executives say, outside agitators are making all this up.

The fact is that labor relations at Cayuga Medical Center began to deteriorate in 2013 when John Rudd completed his ascent to the top spot after running the financial side of the business.

And it is a business. Hospitals get to be “non-profits” — that is to say they are excused from paying taxes — on the condition that they return something to the community. Nobody ever pinned down exactly what that something should be, so hospitals generally toss a token into the community chest, just enough to placate whoever does their taxes.

And there are other creative ways to maximize revenue. Rudd had been overseeing the hospital’s books since 1996 and was Chief Financial Officer in 2012 when Cayuga paid more than $3 million to settle charges of defrauding Medicare and Medicaid. That’s the kind of initiative that gets noticed in the board room apparently, because the directors voted unanimously to name Rudd the Chief Executive Officer the following year.

The year after that was a prosperous one for the board.

Rudd purchased nearly half a million dollars worth of computer products from a company called the Computing Center, which is owned by CMC board chair Larry Baum. Rudd also threw some business to Tompkins Trust Co. CEO and CMC board member Gregory Hartz — banking fees to the tune of $174,000. Board member Steven Rogers, MD, who owns Triphammer Medical Realty, out on Triphammer Rd., collected nearly $150,000 for renting office space to CMC.

2014 was also the first year in recent memory that CMC nurses did not get a Christmas bonus. Hard times all around at Cayuga — except for those in the executive suite, where officers in the company rewarded themselves for posting a nearly $3 million loss in revenue by ladling out bonuses and raises all around, with Rudd helping himself to a $70,000 gratuity and a 17% salary increase. That puts the CEO at about $500,000 a year, which translates to about $250 an hour — for sitting behind a desk in a Herman Miller chair thinking about ways to keep the workers from organizing.

Meanwhile, caring for the city’s casualties down in the ER, nurses are cleaning shit, piss, blood and vomit off their uniforms in life and death struggles, working 12 hours shifts for little more than 1/10th of that. They have to fight for a single, half-hour break.

With management becoming increasingly disengaged and unresponsive, and resources being diverted to higher priorities, blue and white pieces of paper began to appear in the break rooms. They were applications for membership in District 1199 of the Service Employees International Union, and they were being filled out. Before long, almost all the nurses in the ER had signed cards in support of union representation. They only have to get 30% of all the nurses to call for an election, but the union would rather make it a fait acompli by having 70% of them on board before a vote. And with nearly solid backing among the 20 or so in the ER, along with widespread support throughout the rest of the hospital, they were almost there last year, according to supporters.

That’s when a subtle campaign of intimidation began, effectively purging union supporters from the ER nursing staff. “Management would mess with the schedules” of workers who had signed union cards, “and give non-union people better treatment,” one former staffer said. “Most left because of awful working conditions, unfair treatment, and fear that patients would get hurt.” A dozen experienced nurses quit the ER over the past year, leaving an emergency room staffed mostly by travel nurses — who are being paid about twice as much as the experienced nurses who live in the community.

As it stands, more than half the nurses want union representation. Supporters believe that if the election were held today, they would win. “People are just scared to come out publicly” for the union, one nurse said, “because they fear retaliation from administration. Many people have told me they will vote yes but are afraid to sign a card in case administration finds out.”

A team from the National Labor Relations Board came to town last spring to investigate the accusations of dirty pool, which management denies.

Rudd calls employees partners, and says that talk of a union “erodes the trust and partnership we have worked hard to build up in one another over time.” People who work at Cayuga are scared to come out publicly for the union because top executives of CMC are scared; threatened by the very idea, frightened of sitting across the table from seasoned negotiators from District 1199, scared about which partners would get the bonuses then.

Rudd — who missed his calling as a Baldwin–Felts detective — takes a paternal, scolding and disappointed stance in memos, telling his CMC “teammates” that they have a good thing going already at Cayuga, a veritable workers’ paradise. Union hospitals, on the other hand, are not happy places. “There are many examples of layoffs, strikes and even facility closures at union hospitals,” he says.

In fact, Cayuga would be in good company if it were unionized. Seven out of the top 10 hospitals in the US News Best Hospitals of the New York Region are union hospitals, as are prestige medical centers like Johns Hopkins, New York-Presbyterian, Mount Sinai and NYU Langone.

“I am also very disturbed by the tactics that have been utilized by these individuals” — you know who you are, you down there in the ER, there in the ICU — “as well as the out of town union employees,” Rudd tells the staff. “We have had many of you express your concern for the bullying tactics that have been used by these individuals to try to pressure you into signing a card,” Rudd says, clearly longing for the days when the National Guard was at the disposal of board rooms across the country. “Unfortunately, there is little that CMC can do legally to prevent this typical union behavior.”

If there is any bullying and intimidation going on, it originates in the CEO’s office.

“We have confirmed that the posting of unsubstantiated claims to a public blog that questioned the quality of care provided at CMC was done by one of the union organizers,” Rudd tells teammates, in other words, we know who you are.

They think they know who blew the whistle on the covered-up Levophed death, but they don’t.

An experienced ICU nurse performed a common procedure last week, the way it is commonly done. She and another nurse went through the identity verification checks designed to prevent a blood transfusion mismatch. One of the nurses went to the patient’s room and obtained informed consent for the transfusion. When the blood arrived, both nurses together double-checked the patient’s identifiers as well as the blood type, batch number, and expiration date. They did this just as they and everyone else has done — standing at the nurses’ desk.

Meanwhile, people in the executive suite were thumbing through the rule book and finally hit on the section about how blood checks are supposed to be done in front of the patient, which was enough to call a certain nurse in for a going over — and a notice of suspension. Further, they called the nurse back for another meeting on Thursday to tell her that there would be more news of her fate come Monday, giving the single working mother a long weekend to deal with the anxiety of probably being fired.

The other nurse involved apparently faces the same fate.

Yes, according to policy, blood checks should be done at the patient’s bedside. And if not for chronic understaffing at Cayuga Medical Center, that’s the way the nurses would have been doing it all along. But management has been looking the other way for a long time on this and other policy violations as a harried and overworked nursing staff try to make do.

The reality is that if there are four nurses on floor, each with three or four critically ill people to care for, it is difficult to justify pulling another nurse from her workflow to come to your patient’s room to go through the procedure when the more practical — and safer — thing to do is for both nurses to meet at the nursing station where they can both keep an eye on the monitors for all their patients while simultaneously doing the blood check.

“This was one of the biggest stressors at work,” one nurse told me. “Barely keeping your head above water and then running around the floor trying to find another nurse to verify insulin or blood. You have a patient circling the drain, and you are spending time finding a nurse to do this for you, a nurse who has her own train wreck to deal with, and you have another patient who needs attention. Shortcuts are a given when nurses are forced to complete too many tasks to fit into their shift — and management is well aware of it.”

It is an illustration of every nurse’s dilemma. Management pushes and pushes and looks the other way when corners are cut out of a necessity born of short staffing, and it becomes a habit. When there is an incident — the nurse takes the fall. Hospital executives are punishing these nurses for a procedural technicality in a case where no one was hurt because they believe one of them exposed system-wide mismanagement resulting in the deaths of at least two patients, as well as injuries and close calls for several others.

But I can tell management that they are retaliating against the wrong duo of nurses. I have been in contact with a number of employees at CMC, and the stories I hear are consistent — the Levophed death is just one example of the injuries and deaths that have occurred at that hospital due to mismanagement of the nursing staff.

Management has been repeatedly been made aware of safety issues and has done nothing.

A Johns Hopkins surgeon once wrote that he came to see that his silence about witnessing medical errors made him an accomplice to the act. The other nurses and doctors at Cayuga Medical Center need to understand this fact: that if they stand by while these two nurses lose their jobs for doing the right thing, if they who have knowledge of these incidents don’t speak up — then they too will be accomplices.

I have been writing about patient safety issues since my wife, a nurse, was nearly killed through reckless hospital care. In fourteen years since then, I have spoken to many healthcare workers at many hospitals. I find that there are hospital executives out there who “get it,” who understand that even though the emergency room may not be a profit center, it is the first line of care for the community and that nurses — and employees throughout the hospital — are not assets to be exploited, but people who need to be supported, encouraged and fairly compensated.

Successful hospital executives don’t have labor troubles. Cultivating a healthy relationship with the workforce is part of the job of the Chief Executive Officer. If the relationship has turned sour — as it has at Cayuga Medical Center — it is a failure of leadership.

Really successful hospital executives have nothing to fear from union organizers. Either the union is already there and they are working with them to provide the best possible care, or the staff feels comfortable and confident enough in their positions that they see no need to join one.

A news story says that when Rudd took over as CEO from Dr. Rob Mackenzie in 2013, Rudd “less than half-jokingly told Mackenzie that he still had his cell phone number and would probably be calling him for advice.”

It’s time for Rudd to make that call and ask McKenzie about the proper way to run a hospital — if he can’t do that, he should resign.

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