Part 2

In difficult financial times, when hospitals are looking to trim (read slash) budgets they start by looking to the largest part of the budget. Nursing is the largest part of any healthcare system budget – sheer volume.  As nurse staffing gets tighter and the number of patients I care for increases, the less time I have to fully and adequately take care of them.  As an ICU nurse I have worked at hospitals with 3-4 ICU patients under my care.  It was physically impossible to turn them every two hours, check their blood sugars every hour, administer their meds on time, send labs on time, or clean them up in a timely manner.  Time would evaporate as I was consumed with tasks, meds, emergencies, baths, tests, procedures, traveling, families, pain, nausea, hypotension, hypertension, trips to the operating rooms, and so on.  Four hours would go by and it would dawn on me that I hadn’t been in to see the quiet patient that needed and demanded nothing.  I am excellent at time management.  Though there were many shifts in which I couldn’t streamline my work enough to account for the unaccountable and I would quickly find myself an hour to two behind again.

I have thought for a long time that if we were able to create an environment that successfully utilized nursing as a cost saving and cost cutting practice; patient care would improve, outcomes would improve, and costs would decrease.

As financial reimbursement for hospital acquired infections has stopped, hospitals have worked to implement every possible device or technique to decrease the cost of central line infections, UTIs, and VAPs.  One technique I haven’t seen is decreasing the nurse staffing ratios and base nurse staffing on patient specific acuity.  It’s a very simple equation; As a nurse the less patients I am responsible for the more time I have to devote to each one.

I have mentioned Swedish Medical Center in Seattle quite a few times in this blog.  They continue to report in the news the layoffs and cost cutting measures they are having to implement because of their continued financial losses.  I understand that hospitals, as altruistic as I wish they were, are businesses.  Within the last 2 years, Swedish has grown exponentially.  The company bought 1 hospital and remodeled 2. They opened 2 stand alone ER’s and a brand new hospital (their 5th). Then they merged/were bought out by Providence Health Care (it’s still grey) and have closed down “non-profitable” though extremely necessary entities (Visiting Nurse Service and Hospice) and are now talking more staff layoffs. It hasn’t been specified if layoffs will involve management, nursing staff, ancillary patient care staff, or parts of the vital building operations departments.

What is missing from that article and obviously the overall layoff and cost-cutting discussion at Swedish, is pay cuts for the CEO and all members of the executive management team.  It is well-known, though never discussed, that the pay for employees in that sector of hospital operations for Swedish are compensated to amounts greater than $1 million dollars and less than $5 million dollars including perks and bonuses.  Most of the physicians are also employed by Swedish proper and pay cuts and physician cut backs have also never discussed.

Hospitals exist to provide 24 hour nursing care.  Physicians admit their patients to the hospital because they are too sick to go home and need to be monitored and receive 24 hour trained, specialized, skilled nursing care.  Otherwise you could have surgery in your doctor’s office and then go home.  As a nurse, I can say with confidence that even cutting nursing assistants and secretaries greatly impacts my job and the care I provide.  It is impossible to be available to answer the phone every time it rings at the desk, help my coworkers care for their patients, and also care for my own.   At this rate and with these continued staffing cuts one will soon be able to see a doctor in the hospital but will never see a nurse.

The Miami Herald on 3.11.2012 published an article written by Carlos Migoya the CEO of Jackson Health Systems about their massive staff layoffs. The following is an excerpt from the article. (The part that is the most angering)

When I was hired last spring, I believed that Jackson’s taxpayer-owners should have ways to hold me personally accountable for our performance. As such, my salary is much lower than the CEOs of other Miami healthcare systems or Jackson’s prior leaders. Instead, my pay is largely dependent upon Jackson becoming profitable. Considering Jackson has no working capital and cannot afford to continue weathering huge losses, this seemed like a fair deal.

Sadly, this arrangement has been used by Jackson’s critics to attack our plan for becoming more efficient. Some have even accused me of demanding layoffs in order to fill my own pocket. Nothing could be further from the truth, and I’m going to prove it.

If we are successful enough to make money for Jackson this year, I will donate every dollar of my bonus to the Jackson Memorial Foundation.

I appreciate Mr. Migoya genuinely wanting to improve the management, the operations, and care of patients at this taxpayer-owned health care system. The word that jumped out of this article immediately to me is probably the same that jumped out at you- bonus. It is true that at most health care organizations, management (executive and middle) receive bonuses for coming in under their operating budget. I challenge Mr. Migoya to openly reject the receipt of ANY bonus as the CEO of a TAXPAYER owned health care organization, both now and in the future. Donating your bonus, to remodel labor and delivery is a lovely gesture, however it is to be assumed then to be a significant bonus in order to make any sort of impact on a remodel.

I find myself constantly frustrated by the idea that a health care organization that is taxpayer-funded, obviously publicly owned, and like nearly every other health care system in America (it receives >50% of its operating budget dollars from Medicare and state Medicaid reimbursement) would ever consider the notion of offering a bonus for coming in under budget or making a profit.

I am heartbroken at the thought that a CEO of a medical organization wherein staff are being laid off and patients are financially unable to pay their hospital bill would write what he will do with his bonus. With that much public funding and federal dollars needed to keep a hospital with an operating budget, the individual directing the management of that hospital should want to see the financial success of an organization such Jackson Health System turn around.  As an employer and health care provider, the domino effect of closing its doors would be catastrophic in the City of Miami; the health of neighborhoods and many populations would crumble without it. Mr. Migoya, I understand the criticism you have received, I think you should use it as an opportunity to reflect on how and why running a publicly funded health care system is different then a private financial company.

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