There are two kinds of disasters, the uncontrollable kind and the kind that can be controlled or avoided altogether. In the middle is “mitigation,” making the negative impact of the uncontrollable as small as possible.
Volcanic eruptions are uncontrollable. The people of Montserrat were not to blame. The Hovensa closing was an uncontrollable disaster, driven by market and economic forces beyond the control of Virgin Islanders. Unhappily, as often happens, members of the territory’s political elite worked to assure that the damage would be as great as possible instead of minimizing it.
Then there are the controllable or fully avoidable disasters. The decertification of the Gov. Juan F. Luis Hospital on St. Croix falls into this category. And to be clear, this is a disaster with no clear pathway out. Coupled with the loss of Hovensa and long-standing social tensions, the loss of a community’s only hospital is the kind of event that gets people to start looking for the exits.
Just to avoid any confusion, the Centers for Medicare and Medicaid Services is not in the business of decertifying hospitals, especially in places where there is no alternative. Decertification is a rare event, reserved for those with really bad records, who refuse to take corrective action after repeated warnings. Nobody is picking on or being mean to the Virgin Islands. The territory has brought this on itself.
To be decertified indicates a level of cluelessness and incompetence that cannot be given a pass. Statements by the hospital’s chief executive officer, Dr. Kendall Griffith, put him at the center of this mess and, as the hospital’s leader, he bears ultimate responsibility, along with the board and other members of the political elite.
Griffith’s misleading statements are pointless, directed to the wrong audiences and send the wrong message.
Griffith’s stated intention to appeal the decertification indicates a lack of understanding so fundamental that it is shocking. There is no appeal of decertification. There is only application for recertification, based on correcting the many deficiencies cited by CMS.
Virgin Islanders have an unfortunate habit of thinking that they can jerk around regulators forever, not realizing that there is always a last straw. That’s what happened here. With respect to the numerous wrong statements that have been made, they all fit into the category of “TL squared” (too little, too late).
Understanding the Problem
It would, however, be a big mistake to point a finger at Griffith and assume that finding “Mr. or Ms. Right” will fix the problem. He is not the problem, and the starting point in finding the best, or least damaging, solution is to accurately name the problems to be addressed. These problems are not the tired doctor who made the insertion in the wrong lung, or wrong labels on medications, or the board’s inability to function. They are symptoms.
Each is symptomatic of deeper issues, many years in the making. None of them will be easy to solve, and some, in the absence of soul-searching and a willingness to confront unpleasant truths, may be insoluble.
Quick fixes or a “bail out” to keep the hospital running won’t work, although they may be needed as a very short-term stopgap. Decertification is the unmistakable signal that the quick-fix, blame-shifting and deflection trains have left the station.
Here is an outsider’s take on the problems that the territory needs to address if it is to have a high quality, functioning hospital on St. Croix. Hospitals are complex entities. The most successful ones are also healthy organizations. Healthy organizations have high levels of trust and a unity of purpose. Everyone pulls in the same direction. There is clarity, a culture of performance, high standards and accountability. Basic systems and processes that really work, and there is a focus on execution, and an absence of politics, silos and cliques.
Many Virgin Islands public organizations have none of these healthy organization qualities. The problems that they face have been decades in the making and have been worsened by recession and austerity. At the heart of the problem is the central reality of public service as a jobs program. As understandable as it is in a place with limited opportunity, it doesn’t work, especially when human lives are at stake as they are in a hospital.
The jobs program makes connections and politics the primary drivers in a setting where they should have no place. It’s hard enough to find good people for many jobs in a hospital. It becomes far more difficult when there is widespread favoritism, a lack of accountability for performance for “protected” people, an inability to fire poor performers and the biggest killer of motivation and quality, a sense of “relative deprivation.” Why should I kill myself when he doesn’t do anything, and we are getting the same pay?
Then there is another Virgin Islands curse, the rejection of outsiders and the false belief that “we” have all the talent we need right here. There is even a unique Virgin Islands’ term for the process of getting rid of these annoying people: it is to be “spampinatoed,” in memory of an Education commissioner driven from the territory in disgrace (and as a warning to others) several years ago.
Keeping outsiders out means keeping insiders in. It also means that these insiders divide things up among themselves, and that “goods” and benefits that should be for the whole community, such as high quality health care, end up getting divided up and degraded for the benefit of insiders. There is a clear trade off: jobs, influence, etc. at the price of high quality care in the hospital.
Unhealthy organizations, such as JFL hospital, aren’t good at management and execution. That is why the hospital was decertified. It could not come up with and implement an effective plan to correct deficiencies that were clearly identified by CMS. And now it – and the people of St. Croix – are screwed.
This is a failure at the executive level, the board level and on the part of the political and other elites who were all willing to take a bite of the apple and ignore what was happening. They all kept dancing until the music stopped. CMS has stopped it.
One member of the St. Croix political elite recently suggested that Crucians should go back and live off the land as their ancestors did. With respect to health care, she may get her wish, although it is unlikely that she – or others – will avail themselves of the opportunity.
The Path Out
Given this toxic mess and the imminent threat to the hospital, what are the choices that the territory faces? And who should make these choices? There will be strong pressures to provide short-term “gap” financing until the hospital can be recertified. (Once again, contrary to Griffith’s statements, there is no appeal process.) Such gap financing may be inescapable, although it is not clear where the money would come from.
What seems absolutely essential is that such financing comes with a set of stringent conditions. The pressure to think of the short term should not obscure the need for long-term solutions. These are conditions that none of the important interest groups, political, management or labor, will like or accept. And the great danger is that there will be a return to some version of business as usual.
At a minimum, there needs to be new executive leadership, a new oversight board whose primary responsibility will be to assure that the CMS identified deficiencies are corrected as quickly as possible. This board should also have the ability to fire poor performers who endanger the health of patients.
Can this be done with local talent and within a context of St. Croix’s often-toxic politics? That is the $64 million question. And anyone who answers “yes” should be required to explain who got the hospital into this catastrophic mess.
The inability to fire poor performers is the crux of the problem, not only in the hospital but in the entire Virgin Islands.
I am also sick and tired of the last names game. These young people who the governor/government is putting in these positions are not qualified. They suck! They just approved Troy Schuster to some Board; I believe it is the hospital board. This is a momma’s boy or man and we all know where he will be getting his direction from. We need proven thinkers and confident actors representing us. Things need to change.
If this does not serve as a wakeup call nothing will! Anyone with options whether it is moving here or staying here has to take very seriously the breakdown of the health care system.I can only pray that this mess can be straightened out, I’m not sure that those in charge are willing to do what is necessary to do that.
Bravo, you have nailed the problem…”At the heart of the problem is the central reality of public service as a jobs program.” Too bad that the solution is beyond the grasp of our policy makers. It cements the fact that this has been the worse administration in the history of the Virgin Islands. The Governor has been asleep at the wheel and has caused a major mash up. We are all the victims. All our public organizations suffer from this problem. I believe Dr.Griffin to be a good doctor but lacking in experience to solve this problem. Have pity on us…..
This is very telling, a first hand account, with observations, suggestions and concerns. It is well worth reading to get an even better understanding of what is going on in our hospitals: I thought it was worth sharing:
“I am a registered nurse with over 17 years experience in non-profit facilities, corporate owned facilities and state
facilities. I have had the privilege of working in a variety of settings: all critical care areas, medical, surgical, OR, recovery unit, high-risk Labor & Delivery, Ante & Postpartum, and disaster relief areas such as Florida and New Orleans.
I’ve seen excellent, mediocre and poor health care. Gov Juan
F Luis hospital is the worst I’ve seen; but not because of
lack of supplies or equipment, not because of a run down
facility, but because of the attitude and lack of
accountability our healthcare community has had; because of
the lack of camaraderie with healthcare workers, and the
lack of community involvement.
For these reasons I do not believe it is only the hospital
at fault that we are now in this healthcare crisis. I
strongly believe the following should all be held
accountable: the hospital staff, our local physicians, CMS,
Joint Commission and our local community.
I left the hospital after 3.5 years because my own
conscience would not allow me to continue to turn a blind
eye to the inhumane treatment our patients received. These
are the things I saw with my own eyes: hep-locks
embedded in a person’s arm, IV tubing and IV sites not
labeled with date, time or initials, dressings that hadn’t
been changed for days, bed sores that could have been
prevented, urine and feces saturated diapers on a person all
day, ignored call bells for assistance, wrong medications
given, no medications given, beating patients, refusal to
feed patients that could not feed themselves and force
feeding patients when they took too long to chew and swallow
the food they were being fed, doctors orders not being
carried out, no policy and procedures and out dated policy
and procedures, doctors not responding to calls, doctors not
coming in when called in, poor working diagnostic machines
(x-Ray, CT Scan and MRI) yet billing for the services,
blankets and pillows along with other supplies being taken
home by staff members for their own use, wrong diagnosis
from doctors, radiology staff sending letters to patients
saying they have cancer when in fact they did not, hospital
walls and ceilings dripping with condensation falling into a
patients open abdomen while on the operating room table, and
more.
While in nursing school I was taught that going to a
hospital is like going to visit someone at their home.
That we should treat each patient as if they were a guest in
our own home; that we should treat ALL patients the way we
would want to be treated and the way we would want our loved
ones to be treated.
Shame on all of you involved in his treatment.
To the clinical hospital staff I ask: How can you
continue to turn a blind eye? How can you document
that an IV is clear of signs and symptoms of infection when
you haven’t even looked at it? How can you document
that you’ve carried out an order and really haven’t ?
How can you not work together as a team when you know full
well that caring for a patient IS TEAM WORK? Why is it
that those nurses that are now in administration cannot put
on a pair of scrubs and help care for patients when there is
a staff shortage? I was told by the Chief Nursing Officer by
the union laws they are not allowed to treat patients once
they’re in administration. Really? Then why did you become a
nurse?
To the physicians I ask: Is it really about the
money? Because that’s what it looks like. Caring for a
patient in a hospital is a “Privilege” for services that you
can charge for. By getting a salary from the hospital as
well as charging for your services is double dipping.
Is it really because a doctor isn’t born here on St Croix
that you cannot accept them as colleagues and work together
as comrades? That question is for nurses as
well.
To the administrators I ask: Why is having a title of
CEO, Chief Nursing Officer, Nurse Manager, Assistant Nurse
Manager, Clinical Coordinator, etc more important than
“Quality Patient Care”? How is it that at the end of
2013 we still do not have a Scope of Practice for Nurses,
Nurse Practitioners, Physician Assistants, etc? How is
it that we don’t have updated policy and procedures for
things like Blood Transfusions? How is it that we
still have inexperienced nurses working triage? How is it
that we still have nursing assistants working as emergency
room technicians without the proper training? How is
that we do not have cardiac monitors in every ER exam
room? Where are we supposed to get our patients for
the new Cardiac Care Center if our front door (the Emergency
Room) is not prepared? Do we really need sooooo many
administrators when we have such a “global” shortage of
nurses? What about overseeing the housekeeping
staff? Surely this small facility could be a little
cleaner. What is it that you are
“Administering”?
To the community I ask: How is it that the community
hasn’t come together to address these issues as well?
Why is the community going off island for healthcare
treatment? Including the same doctors that were born
here and live and their family members? Why is the
community not actively protesting to have better
healthcare? Why aren’t asking questions and demanding
answers? Why is the community NOT
OUTRAGED!!!!!! at our healthcare here in the
territory? It is your body, the body of your friends
and family that are being neglected, mistreated and
misdiagnosed. Do you not care about yourself and loved
ones? And lastly you need to know that most of us got
into healthcare because we really do care. We’re not here to
give you a hard time; we’re here to take care of you and
your loved ones. So when we ask something of you please
remember that. It doesn’t help when you treat us badly
like cussing at us or threatening us with harm. You
cannot put a price on saving someone’s life. We don’t get
paid that much!
To Joint Commission and CMS (Center for Medicare &
Medicaid Services) I ask: If a hospital is to report
to both agencies as governing bodies then surely you should
be held accountable as well. Clearly the hospital did
not get to this point over night? Both agencies also
turned a blind eye. If you hadn’t our hospital would not be
in the situation it is in today.
CMS is the agency that governs Medicare and Medicaid
services. It sets the rules and regulations hospitals,
long-term facilities and laboratories must follow and meet.
“Founded in 1951, The Joint Commission seeks to continuously
improve health care for the public, in collaboration with
other stakeholders, by evaluating health care organizations
and inspiring them to excel in providing safe and effective
care of the highest quality and value. The Joint Commission
evaluates and accredits more than 20,000 health care
organizations and programs in the United States. An
independent, not-for-profit organization, The Joint
Commission is the nation’s oldest and largest
standards-setting and accrediting body in health care. To
earn and maintain The Joint Commission’s Gold Seal of
Approval™, an organization must undergo an on-site survey
by a Joint Commission survey team at least every three
years. (Laboratories must be surveyed every two
years.)”—copied from http://www.jointcommission.org.
—-did you hear that—–every 3 years for the facility and
every 2 years for the laboratory!!! Where were these
guys? Not here, or maybe they were paid
off.
I’ve often wondered why the United States needs two agencies
to oversee the requirements that are mandated by “one”
CMS. It just sounds like more money for us tax payers
to pay.
And lastly to our local government I ask: All of this
starts with you, the government. What are you thinking
of? These are your people you are representing, yet
you too leave the territory for better healthcare. Why
aren’t you taking stronger actions for us regarding
healthcare? Why is it that individuals still cannot
get health insurance here? It’s been over 3 years now.
How much longer are you going to negate what is rightfully
ours? This community trusted you and the education you
received to do better for us. You have
failed us as well. You should be setting the example for
those of us in the community and yet you shame us.
This hospital was set up to fail from the beginning it was
just a matter of time before it finally was brought to the
forefront. An organization that has so many people in
high paying positions cannot sustain without falling at some
point. An organization that has no inventory control cannot
sustain with falling. An organization that continues to turn
a blind eye at the inhumane treatment of another human being
cannot sustain without falling! An organization that
does not hold itself or it’s governing body accountable
cannot sustain without falling. There are too many variables
to deal with on a daily basis, including but not limited to
the constant changes and demands from CMS and our local
government.
So now for some solutions:
–This community MUST!!!!!!!! Get REALLY, REALLY ANGRY!!!
–This community MUST!!!!! Get INVOLVED and EDUCATED in
basic healthcare current events.
–This community MUST!!!!!! Raise it’s standards and stop
accepting mediocre at best.
–This community MUST!!!!! Pay attention to their own
healthcare as a whole and STOP blaming the healthcare
professionals. Ask your nurses and doctors questions
so that YOU understand what exactly is happening to you and
what exactly are YOU being treated
for. Keep a list of your medications, past
medical and surgical history and your doctors names and
phone numbers in your wallet. Know what each
medication is and why you are taking it; not just its color
and size. These are your responsibilities not
ours. The same way healthcare professionals have
responsibilities, so do you.
–This community MUST!!!! Ask CMS and Joint Commission for
an explanation of why they have continued to give the
hospital here accreditation when clearly they shouldn’t
have. Also to possibly work a little closer with the
hospital to get it to be where it needs to be to meet the
standard of quality patient care we all deserve.
–This community MUST!!!! Hold the government to their word.
Next:
Create a financial analysis. A lot of the money that
is needed is within the hospital.
Create an IT analysis so that we do not continue to spend
money on electronic equipment we do not need. Remember
CMS is constantly changing their requirements. They now want
all electronic health record systems to be web based. I hear
no one talking about the exorbitant amount of money that has
already been spent on these systems.
Create a bartering system where patients that owe money can
work off part of their debt. I.e. Electrical, plumbing,
painting, IT etc., services the hospital needs to maintain
its facility can be done by our own community.
Then:
–Get rid of administrators that are clearly NOT really
needed. This is part of the financial analysis.
I’m not saying to fire them, but maybe demote them or
cross-train them to do other needed services. Those who are
nurses should assist as needed when their is a nursing
shortage.
–Take away doctors salaries from the hospital and allow
them to charge for their “privileges” / services.
–Create up-dated policy and procedures and keep them
updated yearly or as needed.
–Have regularly scheduled in-services for the staff re: the
policy and procedures.
–Create standing orders for the emergency room (ER) for
various common symptoms I.e. Urinary tract infections,
chest pain, shortness of breath, asthma, etc
–Place cardiac monitors in every ER, intensive care unit
(ICU), progressive care unit (PCU) room and have a monitor
tech monitoring them.
–Have only seasoned experienced nurses working triage.
–Have only ER techs assisting Registered Nurses in the ER,
not licensed practical nurses (LPN’s) nor certified nursing
assistance (CNA’s)/patient care technicians (PCT’s).
ER techs can: draw blood, star IV’s, get EKG’s done,
transport patients, do glucose finger sticks.
–Have CNA’s/PCT’s assisting LPN’S and RN’s on the medical
and surgical wards.
–Have only RN’s working in the other critical areas with
CNA’s/PCT’s assisting.
–Hire a Nurse Educator to offer in-house Continuing
Education classes such as Basic Life Support (BLS), Advanced
Cardiac Life Support (ACLS), Pediatric Advanced Life Support
(PALS), and Neonatal Advanced Life Support (NALS),
medication errors, HIV and Aids, EKG monitoring and reading,
infectious disease etc keeping everyone current and up to
date with their licensure requirements.
–Cut back on paid holidays.
–Continually educate staff on the diversified culture we
have in our community. By doing this it can decrease a
lot of the frustration both nurses and patients have
–Hold ALL staff accountable for their actions by doing
regularly scheduled reviews, addressing insubordination
issues and medical errors, etc
–Obtain an inventory supply system such as an Omnicell and
a small staff that monitors inventory control.
–Modify radiology, dialysis and rehabilitation units
——-I’m sure there are many other solutions out
there——-
And finally, we all need to look at our own attitude and
make the changes within ourselves. As healthcare
professionals we are taught to improvise when we do not have
the supplies we need. This is a small town where
people working together as human beings can make it a great
town. Not more, better, bigger or faster; just working
with what we already have. Maybe improvising a little
when needed.
This is not a “state side or corporate America” way of doing
things; I believe it’s just a humane way of doing
things. It doesn’t cost a cent to be kind to one
another.
After putting opinion to paper why do I feel like I’ve just
wasted my breath? How discouraging …..”
Now what??
I worked there as a traveler on 2 different occasions in 2006 and 2009. You hit the nail on the head about the administrators. The majority of them have their position because of their last name. Way to many politics and family getting family jobs. Only place I ever worked where the assistant would have a assistant. Ruben Malloy was over Ancillary when I was there and he had no background in healthcare at all, his specialty was IT but because he was a Malloy he got the job. I could work the weekend and it would go smoothly because admin wasn’t there but come Monday morning you could find a parking spot and it didn’t run so smoothly.
My friend stuck around to be the interim director of ICU until they could find someone and she would wear scrubs to work and get out there and bust ass to help out. She tried to discipline a staff nurse while she was there and was told nothing could be done because she was union. Joint Commission came in while she was there and started asking who everyone was and when the assistant and assistant to the assistant told them title he told them to leave and laughed saying that is the only place he had ever been where everyone has an assistant.
They need to clean that whole administration out and bring in an outside company to get that place running right but they won’t do that because to many family members would lose their jobs.
VI Watchdog
You are wrong on several counts
DeJongh was responsible for almost half of the CMS citations:
1. Refusal to appoint a governing board for day to day oversight, which was the first CMS criticism
2. Refusal to exempt nurses from the 8% cut! driving 12 nurses out the first week after the cut, leading to the nurse staffing shortages that CMS described
3. Insistence on early retirement if the most experienced nurses in his Economic Stability Act which by the way, collapses the pension system
It seems as if you are eager to criticize the hospital but refuse to cite the governor for his contribution to decertification.
The other point that you are wrong about is that CMS does have an appeals process. That is what they put on their cover letter to Griffith. You are treading on libelous ground. No agency of the US government is allowed under the constitution to give a ruling without due process. Look again at the CMS website.
Their were some things taken out of context. Of mislabeled medication, what percent was mislabeled? And what if any is their acceptable error rate for any infraction? And did the hospital have a policy against mislabeling?
And in the case where a patient died after surgery CMS flat out lied that the hospital had no response. That doctor lost his privileges that same week. Would you like to know his name?
The hospital has work to do yes. Four different CEO’s told them that continued gubernatorial budget cuts would jeopardize certification. Including the stateside Jeff Nelson. But the report is disingenuous in some places, and blames the governor in others. And if you are going to criticize, give blame where blame is due.
I look forward to the hospital fixing issues that they can and appealing the parts of the report that are out of context. Meanwhile, we can only pray that the governor grows a conscience.
I
Well said and written. Hit the nail on the head. Griffith has to go. No doctor deserves nor is qualified to be CEO. Best thing to do would be to clean house and start fresh. Start at the top and work your way down. Try not to lose any bodies on the way down either! My wife is a former employee and said her biggest problem was that all these bad incidents continued to happen and nothing ever changed as a result of them.
VI Watchdog
Griffith is only the Interim CEO, never intended to be permanent. But how can you have appointed a new CEO with no governing board to do it? DeJongh refused to appoint 6 of 7 board members for 7 years! That was the first criticism on the CMS report that this author conveniently forgets to mention. No one would agree to come and work here when the government is trying to get the hospital to lose accreditation just so they can stick the medical school in Stt. Sounds preposterous but why else would he cut the budget, cut nursing salaries, dissimate board quorums, and not pay their agency bills to the hospital? The real problem with Griffith is that he was foolish enough to accept this suicide mission.