The text of the letter to the hospital administration follows:
To the Administration
Marin General Hospital
At the meeting of the neurosurgical section on 8/17/95, the agenda included a discussion expressing serious concerns regarding the nursing care rendered our patients at Marin General. The discussion revealed a surprising unanimity of opinion relative to the quality of care, and in addition, certain perhaps unexpected turns. I have been requested to summarize the discussion for you in this note.
From the beginning it was clearly apparent that there was no member of the neurosurgical staff, or any report from neurology, which expressed confidence and satisfaction in the quality of care currently rendered.
Each member had a lengthy litany of individual experiences dealing with patient care, errors in inappropriate treatment, dangerous events, and lack of understanding of the problems that seemed almost universal. We are all concerned by the seriousness of the events, the nature of the errors. In addition, it is fair to say that no one was unaware of a feeling of increasing patient discontent which seems to be spreading.
In the course of the discussion all agree that there would be little to be gained by detailing the minutia of these events, and it was similarly a unanimous opinion that every effort must be extended to reverse the current trend and to return to the quality of nursing and patient care upon which we had learned to depend in past years.
From these discussions it was evident that all present did clearly understand that cost cutting is essential, and economizing must be initiated in an effort to solve these problems. Even in these early stages it is clear and apparent that the current Marin General effort is a dismal failure. This produces a prospect for the future which is frightening but seems virtually inevitable unless it can be stopped.
During hallway discussion in the past we have been led by planners and administrators to believe that we "do not understand the problem" and that "everything will be all right." Neither is true. Without meaning or wanting to detract from the efforts that have been rendered to solve the problem, it is vital that we all band together and recognize that the wrong decisions have been made. We are heading in the wrong direction. Events have made it apparent that decisions, although well-intentioned and planned, have turned out to be incorrect and need to be reversed now! "Technicians" drafted from more simplistic tasks, and following a brief "indoctrination" cannot be magically transformed into "health care technicians" merely by the application of a new name. Perhaps our forebears were too severe in observing "you can't make a silk purse out of a sow's ear." The fact of the matter remains that we depend upon our colleagues attending the patients' daily needs, and their skill, care, and experienced judgement. While we are not implying anyone does not sufficiently "care," the truth of the matter is that "technicians" do not realize the importance of taking regular temperatures, or turning a patient, or recording their findings properly in the chart—or any one of the other multitude of seemingly understandable oversights which are important! The fact remains that these seemingly minor omissions are preparing the way for a major disaster. We discussed at length the kind of indoctrination provided for these care givers, and it does appear that great effort was expended in these efforts. The major source of this problem rests not in the attitude or the brevity of training of these individuals, but in the fact that the experience these people lack (and which has been lost with the removal of experienced nurses from the staff) has to be retained. We can't force ourselves to understand that a good attitude, nice indoctrination course, and a new and fancy name for the job, unfortunately, does not make up for absence of the long training, skill, experience and other factors that are the essential background of the nurses for whom they are vainly trying to substitute. Yes, they are cheaper, but in the long run they are going to cost much more.
No one needs to be reminded that the source of the difficulty lies in the fact that medical care is too expensive. This is accentuated by and in some measure results from the fact that about one-third of the patients in this hospital have no insurance or other source from which their medical expenses can be recovered.
As if all of this were not bad enough, we now have a new abomination called "managed care." This is a difficult term to define, but it has something to do with the kind of phantomized thinking that makes someone believe (?) that some or even any of these problems can be solved by turning them over to insurance companies and their "managers." These individuals may be excellent "bean counters," but their virtues are not contaminated by any understanding of what is important in the operation of a hospital. Someone must eventually make clear that the "bottom line" in a hospital is patient care. Stockholders' profits, CEOs' salaries, and misleading advertisement will never solve these problems. They are entirely motivated by profit.
While the foregoing is clear, it does seem that the picture is not as bleak as some would have us believe. It is evident from the events of the past few years and projections for the near future, that the hospitals in forthcoming years will be smaller. It is likewise true that many of the patients who formerly populated our beds will be treated with either shorter stays or as outpatients. This is a fact of life. What seems to have escaped notice, however, is that while the hospital of the future will be numerically smaller, the percentage of "ill" patients will be considerably higher. Those who are less ill will be treated either as outpatients or in convalescent-type facilities. As a consequence—and here is the real bottom line—the training, skills and background of the people caring for them in the hospital will have to be higher.
The hospital of the future will consist of an intensive care, and a considerably higher percentage of the total beds will be of the intensive care or near intensive care variety, and a considerably smaller percentage of the total hospital population will be people like many of those currently inpatient who are less acutely ill. Under these circumstances, the really vital thing for survival for the hospital is to perform its function—which will require the preservation of experienced R.N.s—who are currently among those being let go because they "cost more."
Like many other hospitals, we are fortunate in having significant numbers of beds which can be—if necessary—administratively separate, and converted to something more "convalescent" in nature.
Staffing in this latter type of section may turn out to be adequate with your current crop of "care technicians." Fortunately, too, we already appear to have an administrative staff capable of arranging such a plan. It seems likely they would prefer such a setting to the real estate management, outpatient service, and propagandizing in which they are currently involved.
In summary, our section feels that we are facing problems consequent to a very well-intentioned but now clearly unwise effort to change the nature of the staff tending our patients. While cost cutting is indeed an essential consideration, we do not feel that cutting costs at the expense of destroying the very purpose for which the hospital exists is a viable or understandable conclusion.
Hospital planners and administrators tend to vie with others for following the latest and most up-to-date trends. This is, of course, admirable, but we must correct the direction in which we are going. I am not sure whether it is fortunate or unfortunate that this same conclusion appears to be seeping though to others, including those around us. As this is being dictated, I hear that about 10,000 people are marching across the Golden Gate Bridge to demonstrate that they too have concerns about patient care—all part of the "problems" noted above.
LAWRENCE H. ARNSTEIN, M.D.
Local Control Of Hospitals Going, Going, Gone
Marin General Absorbed By California Healthcare Joined To Sutter Heath Hospitals
BY JOAN REUTINGER
The California Healthcare System, of which Marin General Hospital is a part, will merge with Sutter Health Hospitals which include Novato Community Hospital. Marin's two hospitals, excepting Kaiser, will merge with Sutter Health.
This means the death of local control, not that we have much since Marin General merged with the California Healthcare System, a huge, private institution..
Mergers seem "in" this season, both for banks and hospitals. Columbia HCA Healthcare Corporation is also angling to take over Good Samaritan Healthcare System in San Jose and smaller facilities in Sonoma, Petaluma and Castro Valley.
People are fighting the takeover of Sequoia Hospital in Redwood City, which is considering an alliance with Catholic Healthcare West. In fact, one retired Sequoia physician said, "Should a private, religiously-based health organization be allowed to dictate policies to a tax-supported hospital such as Sequoia?"
Of course, Marin General is no longer a tax-supported hospital, although it started out that way. One physician at Marin General says, "mergers are like turning the hospital over to Japan. There will be less and less local control. Not that the doctors have any say now, since it's been a for-profit hospital."
Patient care at Marin General is deteriorating. There have been vast cuts in nursing care, starting with the lamented float team, housekeeping has gone downhill, as has the switchboard. Only the administrators' salaries have not been cut. They have increased every year since 1992. Since that time other employee compensation has dropped more than 30 percent.
And there are rumors that the Family Doctors' Medical Group in Vallejo is not too keen on being taken over by Sutter Health. One doctor in the group said they have "mutually agreed to say nothing," but we all know what that means. The doctors are afraid of losing their jobs at Vallejo Hospital, as (equally a rumor) it is feared that doctors who belong to the Independent Physicians' Association (IPA) know that Sutter wants to control IPA and remove the physicians' power over the hospital.
One doctor who did not wish to be named said that "mergers limit the choice of patients and physicians to compassionate care. It also allows a huge single organization to have computer access to your personal life."
There is no doubt that doctors are fast losing control of their own hospitals. In a money-making hospital, all power rests with administrators. And mergers only make it worse, because the far-flung administrators care little about the patients. They only care about money.
"Managed Care" Is For The Birds
BY JOAN REUTINGER
One of the reasons that hospitals are in such a financial fix these years is "managed care." For those readers who don't know what "managed care" is, here is a brief rundown.
Instead of paying for each procedure, insurers agree to pay so much a year for a patient's care, no matter if the patient has a head cold or a heart attack.
In theory, "managed care" is supposed to encourage preventative medicine and keep patients out of the hospitals. In practice, it is causing the crisis in the hospital system all over the country. Patients are being treated in less expensive outpatient clinics when such care is not appropriate. As a result, hospitals are left with vacant wings or floors.
As an example, the San Francisco Chronicle recently ran an article saying that "in the nine-county Bay Area, there are 73 hospitals, yet only 39 will be needed in the next decade." For an example, it gave Santa Clara County, which has 13 hospitals, licensed for about 3,800 beds, but only 1,909 are filled at the moment. We owe it all to "managed care." It seems we have too many hospitals.