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Palomar omerado Health

BOARD OF DIRECTORS

REGULAR BOARD MEETING

Palomar Medical Center, Graybill Auditorium, Escondido

Monday, February 7,2005

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To: PPH Board of Trustees

From:Chaplain Bill Hard

Subject: Recitation

Date: 02-07-04

SOMETHING MORE

God has given us all this---and more!

Do we, sometimes, feel as if there is something better than what we are now experiencing, waiting for us just around the corner?

Or, maybe we feel an urgency to discover something more that is just beyond our grasp. The feeling is right; there is more! Even with all that we now have and hope to have, God has something more for us!

It is Gods good pleasure to give us the kingdom, which includes health, inner peace, and unlimited abundance! So whether we feel that there is more waiting for us in a certain career or in a more fulfilling relationship, we know that God is always ready to give us more love, joy, and peace, for;

"Is not life more than food, and the body more than clothing? Look at the birds of the air; they neither sow nor reap nor gather into barns, and yet your heavenly Father feeds them. Are you not of more value than they?" Mt 6:25-26

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• PAUL C. MILLING, M.D.

A Professional Corporation

Diplomate American Board Orthopaeclic

163 North Date Street

Escondido, CA 92025

760 746-7965 Fax 7607454766

January 12, 2005

Michael Covert, CEO

Palomar/Pomerado Hospital District

15255 Innovation Drive

San Diego, CA 921 28-3410

Dear Mr. Covert:

This letter is to document some of the problems that we have with the Palomar Operating Room Department, to illustrate the problems, and to request that they be solved in a timely manner. You and the Board of Directors are the ones who can break through the bureaucratic inertia that exists at Palomar.

Example 1: •

On December 1, 2004, a trauma case presented in the Emergency Room at approximately 7pm. The 55-year-old Escondido City employee had a motor vehicle accident and sustained an open femur fracture, fractured patella, fracture of the acetabulum and facial lacerations. I put the case on the add-on schedule at 8pm. The. two evening OR crews were busy in surgery. I requested the designated "trauma crew" be called in from home for this trauma case. By County guidelines, we are supposed to have a crew readily available within 30 minutes for trauma cases. When the crew arrived, they were told to do a recently added on "emergency c-section". At• that point, there was no crew for trauma cases. The open femur fracture trauma had to wait. In the meantime, two more c-sections were put on the add-on schedule. I was told that these were not "emergencies" nor were they elective. They would, however, bump any other case on the schedule and, if needed, the trauma crew would do these also until one of the other rooms finished. I was finally able to get started at 11:30pm. and finished at 2am. I also had scheduled another femur fracture from the ER in a 1 6-year-old girl. The parents elected to transfer their daughter to Scripps Memorial.

This is a routine practice at Palomar, in that the "trauma crew" is not truly dedicated and available within 30 minutes for trauma cases as required by the County. They

are also used for c-sections. It is also impractical and impossible for many crew 5

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January 12, 2005

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members to be called, drop what they are doing, get dressed, cleaned up, drive to the hospital, have to scrub, change clothes and be available within 30 minutes. It is hard enough to be able to do that if you live on the other side of Escondido and most of these people live outside of Escondido.

Example 2:

Last month, I had three patients with fractures from the Emergency Room who presented before 2p.m. I was told I could start them around 5pm. In actuality, I finally got started after after 8p.m. and finished around 3a.m. The schedule for the next day was full so that if I delayed the cases, they would not be scheduled until the next evening. Doctors and staff should not have to unnecessarily work at those late hours just so Palomar can be "efficient". Patients should not have to suffer prolonged pain waiting for surgery and then be operated on by tired doctors and staff. "Efficient" is a word used by the administration when they deny understaffing exists.

This also illustrates the shortage of staff that exists in the OR at Palomar. We are understaffed for the large volume of work that is done, especially in the evenings with the large add-on schedUle.

The Premier OR study done about two years ago showed Palomar has twice as many add-on cases as other hospitals our size. No wonder cases are done into the early morning hours routinely.

We dont have a 24 hour, 7 day a week dedicated OB crew and anesthesiologist like Pomerado, our competitor hospitals and every other major hospital in San Diego. The American College of Obstetrics and Gynecology has a 30 minute guideline for emergency c-sections from the time a c-section is called. Several recovery room nurses have said to me that they fear there will be a major fetal catastrophic event some day because it happens on occasion in the evenings that every available crew and anesthesiologist is working on a case and the "true emergency" c-section has to wait. In addition, when c-sections bump surgical cases that are on the add-on schedule, it delays those patients and surgeons. This causes the on-call crews who have to work the next day to get home later at night and causes increased dissatisfaction and decreased morale among staff and surgeons.

What about Pomerado?

From my perspective, that is the good news. Ask any nurse, surgeon or anesthesiologist that knows each OR whether Pomerado OR is better staffed than Palomar. They will say that it is. Ask the administration and they will say each one

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January 12, 2005

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is staffed equally but Palomar is "more efficient". This efficiency decreases quality patient care and decreases staff and doctor morale. It decreases patient safety also.

This is not a new problem. The present administration has taken some steps to improve the situation 'but not nearly enough. This administration talks a good game about becoming a magnet hospital. At Palomar, in contrast to Pomerado, we are not run like a magnet hospital. There is a definite discrimination in how the administration staffs each of the two public hospitals, operating rooms, obstetrical OR crew and obstetrical anesthesiologist coverage. The patients (customers) at Palomar from the Escondido/San Marcos area deserve the same expeditious care in the operating room for surgeries, c-sections and obstetrical anesthesia as the Poway/Rancho Bernardo patients (customers) at Pomerado Hospital. It is no wonder that the Gallup poll results show increased customer satisfaction at Pomerado compared to Palomar when their surgical and OB experience is different. This disconnect amazed me even more when I was told by a top administrator that Palomar made a profit last quarter and Pomerado did not make a profit. The same administrator could not tell me if one or both hospitals made a profit last year.

All cost centers are not created equal. The public expects the operating room department to be of the very highest quality. They expect safety in the operating room. Forcing doctors and staff to do surgery late at night when they are tired because the administration chooses "efficient" over adequate staffing is not conducive to a safe surgical environment. Doctors cant get their patients into an operating room during reasonable hours. This increases the chances for problems to occur which leads to lawsuits. We are so accustomed to working under these conditions, hearing the same excuses from the administration as to why it cant be better, that we forget that our patients and the public expect the doctors and staff to be their advocates for ensuring they get the highest quality and safest care possible, especially in the operating room. The faceless, unaccountable finance types in the administration who control the allocation of resources are certainly not patient advocates. They look at the operating room as another cost center just like any other cost center. Their main concern is efficiency, not high quality patient care and safety. The finance types, in contrast to surgeons, staff, patients and the public, dont think the surgical OR should have an extra margin of staffing to ensure high quality patient care, safety and protection from mal-practice litigation.

The finance types dont understand that Palomar OR cant be measured by the same staffing requirements as Pomerado or other similarly sized community hospitals. The fact is we are North Countys only trauma center. We dont have 24/7 totally dedicated obstetrics OR crew and obstetrics anesthesia coverage like Pomerado and other major hospitals around the county and country. Our traveling OR nurses have mentioned they cant believe we dont have 24/7 dedicated coverage because the

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other major hospitals where they have worked have constant coverage. Palomar has a higher percentage of very sick patients who require more staffing. Pomerado ER does not have a neurosurgical, plastics, neurology or hand call panel. Pomerado doesnt always have a vascular call panel. As a result, emergencies in these specialties are transferred to Palomar routinely, often in the evening. Many of these surgeries utilize three to five or more hours of an OR crews time. This impacts our add on schedule because the other rooms are always fully utilized with elective cases using block time. Since the weekday schedule is so heavy in cases going to the late evening and early morning, surgeons cant get their semi-emergent cases on the schedule at a reasonable working hour. This causes them to schedule their cases on a Saturday or Sunday add-on schedule. The ORs are again full during the day and emergencies from the ER on the weekends have to wait in line to get into surgery, usually not until late afternoon or early evening. In addition, they are often bumped by c-sections because we have no dedicated OB crews and anesthesiologist on weekends.

Pomerado has a 24/7 OB dedicated coverage. Palomar, for the, first time this year, has 1 2/5 dedicated coverage, that is 7am to 7pm Monday through Friday. Palomar, therefore, has dedicated coverage, similar to Pomerado and other major hospitals 35.7% of the week. This is a "patchwork" type program. It is not a marketable idea that customers would think acceptable. This is not how magnet hospitals operate. This makes even less sense when one takes into consideration Palomar does far more deliveries, epidurals and c-sections than Pomerado. Palomar averages around 378 deliveries per month. Pomerado averages 90 to 100 per month. Why are Palomar mothers and babies not treated equally and as safely as Pomerado mothers and babies?

Our anesthesiologists have recently discovered that the anesthesia department at Pomerado is supplied with medications from the Pomerado Pharmacy that the Palomar Pharmacy has said there was a national shortage of and was unable to supply the medications to the Palomar anesthesiologists. This type of inequality is pervasive throughout the system.

It is not uncommon to hear ER doctors, surgeons, nurses and technicians from the OR, ER and radiology comment that they will work at Pomerado but dont want to work at Palomar because of the chronic understaffing for the amount of work needed to be done, especially in the evenings and weekends. This leads to increased stress levels, too much call and overtime. This results in a lifestyle which is undesirable and leads to burn out, with increased staff turnover.

It is only a matter of time when one of these avoidable late night and early morning cases will turn into another nationally known tragic surgical embarrassment for PPH such as "The Retractor Left in the Abdomen". Other professions responsible for the

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January 1 2, 2005

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lives of the public such as airline pilots dont have to work in an environment which is unnecessarily structured in such a way that it increases the chances of a major problem.

I acknowledge there is extreme financial pressure on the healthcare delivery system. The finance types have an extremely difficult job to do with limited resources. The argument may be made there is no more money to go around for increased staffing. If that is their position, then there needs to be a reallocation of resources between the two institutions to reflect the higher amount and intensity of work that is done at Palomar compared to Pomerado. Pomerado, is referred to as the "Country Club Hospital" by the hospital and medical staff. There is a reason for this comment. It appears Pornerado has historically been given a higher priority. Why?

Employee and physician morale, patient quality care and safety and customer satisfaction Gallup poll numbers will all increase when this situation is rectified.

In summary, please assist Palomar patients, staff and doctors with these OR and OB staffing problems. We have waited for years for changes in the OR at Palomar to make it as customer friendly as Pomerado. Palomar is promoted as being North Countys only trauma center. Palomar promotes their obstetrical unit The Prcrposition BB Committee promised better trauma and ER care in their campaign for their half a billion dollar bond issue. We should have the staffing to back up these promotions. New expensive buildings dont provide care.

Sincerely,

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Paul C. Milling, M.D. LI

PCM/sem

cc: Nancy L. Bassett, R.N. cc: Linda C. Greer, R.N.

cc: T.E. Kleiter

cc: Bruce G. Krider

cc: Alan W. Larson, M.D. cc: Marcelo R. Rivera, M.D. cc: Nancy Scofield

cc: Chairman, Department Orthopaedic Surgery cc: Chairman, Department of Surgery.

cc: Chairman, Department of Anesthesiology

cc: Chairman, Department of Obstetrics/Gynecology 5