Hospital (16 page)

Rivera was a registered nurse, in her forties, pretty, with big, round, dark eyes and hefty from weight gained incrementally with the birth of each of her three children. Spanish was her first language; she didn’t learn English until pre-K. Her parents were from Puerto Rico. They had one message for their three children: “You gotta go to school, you gotta go to school, you gotta go to school.” One became an accountant, another a teacher, and Rivera, a nurse. “I went to Catholic school, Our Lady of Sorrow,” she told me. “When I look back at my autograph book from eighth grade and it said profession, the answer was ‘nurse.’”

None of her three kids spoke Spanish, and she spent most of her time moving patients through the system, but she wasn’t a machine. Sometimes she needed to see firsthand that she was helping.

“Every day we collect clothes to give to patients who come in without clothing, or medication budget for folks coming through ER,” she said. “I had a thirty-one-year-old coming in needing insulin he couldn’t afford to pay for. He told me he survived on a can of tuna fish a day, an illegal, Mexican. My drawers are filled with stuff—glucose monitors I can give out as charity. This man would be compliant if he could afford to be. We charged him a sliding-scale fee, whatever he could afford, because he was working off the books. About five days later, he knocked on the door downstairs and carried in a floral arrangement the size of this table. I started to cry. ‘Why did you bring this? You can’t afford to eat, you shouldn’t do this.’ He said, ‘
Señora, yo quería.
’ ‘I wanted to.’”

Charity was random and unofficial. Getting paid kept the hospital in business. Enter the documentation specialist, whose job was to review charts and make sure doctors had filled in the diagnosis correctly—not for treatment but for reimbursement. The government issued thick manuals of diagnosis codes listing tens of thousands of code numbers, indicating diseases and their gradations.

Say, for example, a patient has a gastric ulcer. There are more than twenty variations on the diagnosis; the addition of specific details indicating severity could drastically change the amount paid to the hospital and to physicians. Precision was required. If you “upcoded” inaccurately about a diagnosis that was reimbursed at a higher rate, the government asked for its money back and could charge a fine as well.

When the documentation specialist taught residents, she brought a stack of charts from recently discharged patients—with patients’ names and doctors’ signatures blacked out—to protect the innocent (the patients) and the guilty (doctors who had screwed up the coding). Over and over she demonstrated the difference a word could make. For bacterial pneumonia, writing “staphylococcal pneumonia” instead of “pneumonia” meant a DRG (Diagnostic-Related Group) paying $14,690 instead of $9,453; noting the cause “TIA—transient ischemic attack, a slight stroke
possibly due to carotid stenosis,
” instead of just “TIA” changed the DRG to one reimbursing $8,851 instead of $6,498. Case by case not much, but making such changes had cumulatively increased hospital revenue by $5 million the previous year.

It seemed crazy. But when I talked to Michelle Spector, a documentation specialist at Maimonides, she said the coding requirements weren’t just some sadistic bureaucrat’s idea of fun. “The regulations are not insane but to make sure that the entire team has similar documentation,” she explained. “The chart shouldn’t look like it’s a different patient on every page. That record is a business document, a legal document, and a big communications tool. You have so many people who don’t speak the same language in this hospital. They have to understand each other’s notes.”

On the other hand, sometimes the reimbursement rules did seem crazy. “What’s off the wall are some of the little decisions some insurance companies make, such as acute blood loss anemia is not reimbursed at the same rate as acute anemia secondary to GI bleed,” said Spector. “You don’t have to understand why, you just have to comply with it. That is part of the game.”

I asked Sam Kopel, medical director, about the difficulty of keeping track. “The charts are so thick with everyone documenting, documenting, documenting, you can’t make your way through them,” he said. “I rely on nurses’ notes, because their handwriting tends to be better, and I rely on the computer. I know all sorts of crap happens to my patients [that] I have no way of finding out, and I pray no horrible things are going to happen until the new computer system is in, in 2009. In the computer at least it’s legible and it will be organized.”

I first met David Gregorius after an early-morning lecture in a dimly lit, windowless room. One of the ER residency advisers had concluded the class by lamenting the disappearance of old-fashioned hands-on doctors. “We have lost the art of the rectal exam,” he told a roomful of sleepy novices. “The eighty-year-old guy who taught you how to do it in school and could distinguish one thing from another by moving his finger around.”

I was contemplating this thought when Steve Davidson, the department chairman, introduced me, telling the group I was writing a book about the hospital and it was okay to talk to me. After class Gregorius stopped by and asked if I would like to see an e-mail journal he’d sent his friends about his experiences. “Of course,” I said.

I finally caught up with Gregorius again for a few minutes in the ER, not long after another lecture, this one from the documentation specialist. He was, as promised, typing into a computer terminal, eyes glued to the monitor, while talking to me, apparently tuning out the din around us.

“What did you think?” I asked him.

He lifted his eyes from the monitor for a second and laughed. “At first, we’re all kind of like, ‘Well, we get paid the same no matter what.’ . . . I can see maybe we’ll get a raise if the hospital makes more money. I ran into her a couple of times on the floor and showed her what I’d done. ‘Check it out! I wrote “Diabetes Type Two” instead of just “Diabetes.” An extra three thousand dollars.’”

Then, back to typing again, he got serious. “You have to learn how to bill properly,” he said. “One of the reasons I wanted to go into ER is because in most other specialties you have to do more business. I just wanted to work at a hospital where you go in and work and then you go home, because I’ve never been really business-savvy. But we get the same thing in the ER. You do a procedure, log it on the chart, because then they can bill for it. If you just put in an IV, apparently, you don’t even think about it, but if you wrote you did it in the chart, the hospital bills them for an extra fifty dollars, just by taking two minutes to write it down. I guess I’m getting better than that. I wonder if they keep track of how much we lost!”

They tried to keep track.

For several years Sondra Olendorf, head of nursing and hospital operations, had been trying to find the bottlenecks. Olendorf at first seemed to have no noticeable quirks; her unfussy short haircut, her manner of dress (conservative but feminine suits, often in bright colors) and way of speaking (vaguely Middle American) were cheerful and direct and would seem unremarkable anywhere else. She had grown up in West Virginia but had spent years working at a hospital in an upper-middle-class suburb of Detroit, where patients were predominantly white, Republican, and well insured and where the institution itself had, Olendorf said, “a kind of corporate culture.” She fit in easily there.

At Maimonides, Olendorf started carrying around a Curious George lunch box. She said she wouldn’t have felt comfortable doing that at her old job, but somehow this oddity now made sense. She explained that the lunch box prevented her from ever forgetting about patient flow.

How?

Olendorf had originally been hired at Maimonides as a performance-improvement specialist, responsible for understanding breakdowns in the system through data.

“There’s a theory of asking why five times, and you’ll get to something you can actually fix,” she said when asked about Curious George, whose imprint wasn’t limited to the lunch box. Olendorf’s office had become a Curious George museum, filled with Curious George dolls, mugs, and clocks. “Early on, I got a reputation for asking, ‘Why do we do it this way? Why does that happen?’ So the second year I was here, during the holidays, someone bought me this Curious George lunch box. So I carry it. It has pens and pencils and a calculator, Kleenex, markers, tape—management tools of facilitation. And now everyone brings me Curious George paraphernalia.”

Olendorf had generally lived her life as the good girl. Her mother ran a grocery store, and her father worked at a steel company. Neither of them went to college, but they were ambitious for their children. She had no choice but to try to succeed. Yet after working her way through nursing school, Olendorf was burned out. She took a sabbatical from responsibility, packed her trunk, and headed for Aspen, to learn how to ski.

At Maimonides she saw the chance to combine responsibility and the thrill of the unknown, in a way that suited her in her fifties. “I need constant stimulation to get to the next good idea, and here everything was magnified and amplified,” she said. “The place always feels sort of on the edge—on the edge of breakthrough of learning and improvement, on the edge of catastrophe because so many things can go wrong.”

The hospital had hired a headhunter to find someone for the performance-improvement job in 1995. When the headhunter contacted Olendorf, an early adapter who had been doing that kind of work for a decade, she said no, she wasn’t a city person. A conversation with someone who knew the hospital convinced her to take a look. She was fascinated by the different types of people, the lines queuing up at the clinics, the strange little brownstones (that weren’t brownstones) that housed many of the administrative offices.

Her husband was ready to make the leap; he had retired from the building business and was making furniture at home. They surprised their grown children: “Hey kids, we’re moving to Brooklyn, New York.”

The door to her office remained open; at first glance the office usually seemed empty. A closer look would reveal Olendorf hunched in front of her computer screen, which provided the only light in the room. She puzzled things through in the dark, a way to shut out the static. It wasn’t noisy on the executive floor, but there was a lot of nervous energy. “We’re overstimulated, overinterested,” said Olendorf.

Even sitting unobserved in the dark carried risks. Once, in the early evening, when it was already night outside, Brier came into Olendorf’s office unannounced, with a physician, to steal some cookies sitting on a table by the door. The director of nursing sat in the shadows holding her breath, hoping they wouldn’t notice her.

Olendorf had been instrumental in improving the nursing staff’s performance and morale, which was at a low after the 1998 nurses’ strike. She managed to be rigorous without insulting anyone, which Douglas Jablon— vice president for patient relations—interpreted as a kind of miracle. “With Sondra Olendorf, I feel she dropped from heaven, and I don’t even think she got hurt,” he said. “I say when God created her, God was just showing off. I remember before her we went through three, four nursing directors. I won’t say they were all hated, but nurses didn’t want to talk to them. Sondra walks on the floor and they throw themselves at her, kissing her.”

In 2000, after she had become head of nursing, Olendorf asked a group of nurses to patrol the hospital to look for problems. They found several:

Patients would be scheduled for discharge, and then the doctors wouldn’t pick up the lab work in time for the social workers to reach family members to pick the patients up. It was taking the cleaning staff eight and sometimes ten hours to get a bed washed, when the actual washing took about twenty minutes. Nurse-to-patient ratios on many floors were one to eight, requiring herculean effort on the part of every nurse; if a patient was discharged, there was little incentive to rush to fill that eighth bed too quickly.

Yet five years later, the problems continued, even after more nurses were hired and more social workers were replaced by discharge planners. Patients aren’t fungible. They had to be distributed by disease and potential for infection, and available beds didn’t necessarily crop up where they were needed. “You have to look at the entire picture,” said Theresa Romanelli, a nurse on the telemetry unit who had been at Maimonides eight years and been chosen to become one of the “bed managers.”

“We have twenty empty beds in surgery, no beds in medicine, and ten people waiting in the emergency room. We’re not going to leave those beds empty. When it’s really bad, in the winter months, we’ll borrow beds from telemetry. But the next day they may be overwhelmed.”

Being a bed manager took Romanelli outside her zone in the hospital and sparked a kind of existential awakening. She had never thought about her unit in relation to the rest, apart from maybe housekeeping and pharmacy. Who has time to reflect on all the links in any chain, how the envelope you put in a mailbox ends up at your mother’s house a thousand miles away, or how freshly washed lettuce ends up in a sealed bag on a grocery shelf, or where electricity comes from, or how patients suddenly appeared in her unit? Suddenly she saw herself and the work she had done as both larger and smaller, part of a giant equation she hadn’t even considered. “Coming from the floor, I was able to see the entire hospital,” she said. “I just didn’t think of anything outside my unit before. I just didn’t. You go to work, you go to your area, you do your shift, and you just leave. You aren’t aware. You have this notion you are working so hard, harder than anyone else. Then you start walking around and you see everyone working so hard. You’re so consumed with your own thing.”

The fact that Maimonides is a teaching hospital added to the complexity. As in most hospitals, the residents belonged to teams. The six medicine teams, for example, distinguished themselves by color: Purple, Yellow, Orange, Green, Brown, Black. Each color had a home floor, and patients were admitted on a rotating basis. So when a doctor from, say, the Brown team came down to “take report,” to prepare for the handoff, the trick was to find that patient a bed on the floor where the Brown team was stationed.