Being Small and Being Great

This is not the usual kind of article I put on this site but I felt compelled to post it. It has to do with the virtues of smaller organizations, particularly in healthcare, and the associated advantages to those who look to such organizations for service. Being small can lead to great results—especially sometimes to those of us on the beach:

The following is a post I made to Facebook yesterday:

“Because of my background I have been debating all day whether I should do this post. I feared that it might seem self-serving even though what happened had nothing to do with any effort by me. I have been watching on social media the last few days the difficulties patients over 65 of very large healthcare systems have had in arranging to obtain a Covid vaccination. I had also been eagerly waiting an opportunity to arrange for a vaccination and the opportunity came on Saturday when I received a text from NorthBay Healthcare that my turn had come to make a vaccination appointment. Many other over 65 year old patients with NorthBay primary care physicians received the same text message. One simply had to click on an embedded link and that brought you to an online scheduling site where it was very easy to book vaccination times for my wife and me. This morning in a well organized process at NorthBay’s Green Valley campus in Fairfield we and many other NorthBay patients received our first shot. As I continue to monitor social media sites I see that the giant systems are still struggling with arranging access to vaccinations for their over 65 patients. Being smaller in healthcare often means being more nimble and responsive. Thank you NorthBay Healthcare for once again living your mission of providing compassionate care, advanced medicine, close to home.”

Here’s to smallness!

Hubris Overdose

The last item I wrote in this space was in October. The continuing onslaught of COVID-19 seemed to me to make all other subjects in healthcare of lesser importance. While the onslaught continues and arguably has worsened, the advent of effective vaccines brings hope that there will soon be better times. As a result, other subjects in healthcare are beginning to be revived and discussed.

This week two developments in the non-clinical area of healthcare which I believe are related caught my attention. One development was in the private sector and the other was a bit of political legerdemain in the public sector.

In March 2019 in this space I addressed the subject of “hubris” by outside private sector experts who really did not understand healthcare:

There is a place for story telling in organizations.  At NorthBay Healthcare we used stories to reinforce our culture.  Stories work best if there is substance to back them up.  Otherwise, the recipients of stories can get cynical.

I thought about stories the past week when “Haven” was grandly announced.  This is the improbable name of the nonprofit organization formed by the CEOs of Amazon, J.P. Morgan and Berkshire Hathaway. What was Haven’s name supposed to convey?

“Haven” to me sounds more like a name better suited for a church or homeless shelter but I am sure the branding experts at these three companies spent hours and many dollars to come up with it.  I could have done it for free for them.

More to the point, was this another ego stroking effort by three prominent CEOs? Was that the story?

The mission of Haven per their website is as follows:

“Our mission is to transform health care to create better outcomes and overall experience, as well as lower costs for you and your family.”

That’s their public story and they are sticking to it.  Notice as usual, the initial emphasis in the mission statement is on quality.  It is only in the last clause they stick in “lower costs” as also part of their mission.

Haven’s CEO, Dr. Atul Gawande, made it clear that the cost of health care was a driving force in creating Haven.  In a memo he said the following:

“Haven was formed by the leaders of Amazon, Berkshire Hathaway, and J.P. Morgan because they have been frustrated by the quality, service and high costs that their employees and families have experienced in the U.S. health system.”

I feel the same way about the cost of my Amazon Prime membership which keeps going up.  And don’t get me started about J. P. Morgan which holds my home mortgage. I hope every month they will lower my interest rate but alas I hope in vain.

I think I will start an organization to address this issue of the costs of super large corporations. I’ll call it “Craven”. No one will mistake that for a church.

More seriously, one can be encouraged by the fact that Dr. Gawande is involved in this latest venture by do-gooding, profit maximizing, publicity seeking CEOs. He has written several compelling books about health care quality.  He also is a very good speaker on this subject.  Whether his leadership will be sufficient to make a difference remains to be seen.

There have been no shortage of other organizations with a similar focus formed by business organizations.  Usually, after a year or two, they wither away as the sponsoring organizations lose interest or focus or change CEOs.

Management guru Peter Drucker once said hospitals were  “the most complex human organization ever devised”.

Given Drucker’s opinion, it is obvious that an internet peddler of goods, a bank which caters to the wealthy and a company which collects other companies are perfectly suitable to revolutionize healthcare including hospitals. You just have to develop an app.

Peter Drucker in his writings recognize that a service industry like healthcare is inherently more complicated than other endeavors like selling and loaning. That does not mean healthcare should be exempt from examination of its practices. That’s happening everyday in healthcare.

I don’t believe the issues of cost and quality are really amendable to a top down approach as seems to be the way organizations like Haven view things.  Even with a star as its leader, Haven seems a reach. Perhaps a better name for Haven would be “Hubris”. That may be the real story here.

This week Haven went down in flames as it issued this press release:

In the past three years, Haven explored a wide range of healthcare solutions, as well as piloted new ways to make primary care easier to access, insurance benefits simpler to understand and easier to use, and prescription drugs more affordable.

Moving forward, Amazon,Berkshire Hathway, and JPMorgan Chase & Co. will leverage these insights and continue to collaborate informally to design programs tailored to address the specific needs of their own employee populations.

Haven will end its independent operations at the end of February 2021.

What gibberish! They got bored and moved on to other virtue signaling activities. Healthcare is harder than the day job these company moguls have. Patients just did not understand what these guys were trying to do nor did they care. Haven devoted a whole two (!) years trying to change healthcare and basically accomplished nothing. Time to move on to something more exciting.

As I indicated two years ago, a top down approach to changing the behavior of patients was doomed to fail. These weird collaborations always fail. Moguls and academic quality experts let their hubris overcome common sense. I am trying to avoid my own brand of hubris but I cannot resist giving myself a pat on the back here on the beach for predicting this result. Feels good.

In a similar vein, a new law has gone into effect which will compel hospitals to disclose prices they have negotiated with health plans. This is supposed to help patients make informed decisions about where they seek care. That is a ridiculous expectation and reveals an abysmal ignorance on the part of Congressional members and their 24 year old legislative assistants. Maybe they should hire older legislative assistants.

Patients’ decisions are not affected by what reimbursement is contained in an agreement between their local hospital and doctor and their health plan. Patients trust their doctors to make decisions that are in the patient’s best interest, not the health plan’s.

Health plans are commodities, middle men who adjudicate claims and yearn to be loved. Health plans would like to be more but no one feels cuddly about Blue Cross and their ilk. It would be like embracing a shark.

Moguls, academicians, pundits and politicians need to get real. They all should be in treatment for hubris overdose. Hopefully they will check the price before seeking treatment.

Happy and Lucky

I have been sitting back here on the beach the last few weeks. Happy to be able to do so.

And while things have been calm on the beach because I will them to be so, it doesn’t take a skilled observer to see the chaos surrounding our political process. No matter where you stand on the political spectrum, you are most likely unhappy.

As my healthcare career continues to recede into my past, I realize how lucky I was to have been in a position to help people get better and be healthy. That may sound a little strange for someone who was not a clinician, but I know I made my contribution to improving the health of my community and even on occasion made an impact on a micro level.

I remember getting a call late one night from a family I knew who had just lost a loved one in a local car accident. Not a chaplain. Unqualified me! They sought someone to help find the resources they needed to cope with their terrible loss. I felt lucky that they considered me that someone who could help.

Nurses are lucky. Physicians are lucky. Therapists are lucky. Clinic receptionists are lucky. Billers are lucky. Environmental service workers are lucky. Even CEOs like me are lucky. We are fortunate to be in healthcare.

When you tell people you are part of a healthcare organization, whatever your job, you can tell from their expressions that they think you are lucky to be so. Whatever your political beliefs, they know that healthcare people put all that aside to focus on the most important person in the world—the person seeking care, solace and, if not cure, assurance they will not be alone on whatever journey is before them

With all the back and forward of debates about the Affordable Care Act, Covid-19, vaccines, increased incidence of depression and behavioral health problems, it is probably difficult for my former colleagues in healthcare to be aware of how lucky they are to be able to be there for others when the need is the greatest.

This is much more philosophical than I am usually comfortable with. As I look around healthcare from a distance, I hope all healthcare workers of all stripes realize they are lucky despite all the daily difficult challenges and real risks they face. And I hope that makes them happy. It always did me.

THE “VISION” THING

This is a more personal bit of musing than I would normally be comfortable in putting in this space. If that might make you as uncomfortable as it does me, you probably should stop here.

Yet as I sit on the beach and look back on my career for lessons that might help others, I cannot help but think that sometimes serendipity plays an important role. Serendipity can have a powerful effect on one’s career.

I have always believed that a manager of whatever rank needs to be able to articulate a view of where they want to be in the future both for themselves personally and for their organization. Call it the “vision” thing.

For me the vision thing began when I accepted my first and as it turned out my only CEO position. Serendipity played a role in that I was fortunate to have as my first board chair a remarkable man who too had the “vision” thing and who encouraged me to develop my own view of the future.

That man, B. Gale Wilson, passed away recently after a very long life. I was asked by my former organization—NorthBay Healthcare—- to put some thoughts to paper about Mr. Wilson and my experience with him. Consider the following a case study of the vision thing and serendipity with a special thanks to NorthBay for their help with editing my thoughts.

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I remember like it was yesterday, the August evening in 1981 when, after spending an entire day in Fairfield being interviewed as a CEO candidate by board members, physician leaders and selected managers, I received a phone call from Gale Wilson at my then-home in Union City.

He asked me to come to his office the next day to “discuss some things.” I had not yet really processed in my mind whether I was still interested in the position. Coming from a much larger health care organization in Berkeley, I pondered if Intercommunity Hospital (ICH) would be the right move professionally.

In his office the next day, Gale talked to me about his vision for Fairfield and the need for Fairfield and Solano County to have a local health care organization it could be proud of. He wanted to see someone develop that vision for the future. Any doubts I had about that CEO position vanished. When he made me the offer, I accepted. So began a nine-year relationship with him as the board chair to whom I reported.

I collaborated with many other talented people, some of whom were already at ICH and some of whom I recruited to join the organization to explore the possibilities for ICH. Together we developed a plan some board members thought was far too ambitious for little ICH and Solano County.  

At the penultimate board meeting before approving or negating the plan and committing the necessary resources, Gale told reluctant board members that I had been recruited to bring change to health care in the county and he emphasized the board needed to live up to that commitment. His comments carried the day. 

That was real leadership. Other board members respected his opinion and judgment.

As board chair, Gale gave me great latitude in the way I did things. He said as city manager of Fairfield his wish was to have the freedom I had to make things happen. He understood, though, that public entities had different constraints than private organizations.

In that first year we made many changes operationally which made some people unhappy. We upgraded rehabilitation services, ended an exploitative contract with an outside firm managing our pharmacy and brought in a new group of well-trained, young emergency service physicians. When I expressed to Gale my concern about the opposition I was getting, his response was, “The dogs may bark but the caravan moves on,” his way of saying he and the board of directors had my back.

Another problem needing to be addressed in that first year was how to meet the health care needs of Vacaville. A few years earlier, a developer had come to town with big promises to build a hospital. When he failed to do that, he left a bitter community. I sensed that bitterness early in my tenure when Gale took me to Vacaville to meet community leaders, all of whom — despite the fact that ICH’s board had Vacaville residents on it — could not believe the hospital in Fairfield could or would do something meaningful in Vacaville. Gale knew I must understand the depth of bitterness in Vacaville about the lack of health care services. He saw Vacaville as a growing community that deserved more services in their community, so he asked me to devote some attention to the issue.

This was interesting to me because many people felt that Gale was only concerned about making Fairfield better and he did not care for any other city. That was an unfair and incorrect judgment to make. Gale wanted all communities in Solano County to progress.

After this visit, my team quickly developed and implemented a strategy that would include opening an urgent care center in Vacaville. Before it began seeing patients, we held an open house on a Saturday. There was a throng of interested Vacaville residents waiting to see this new service from ICH. It was then I truly realized that Gale sagely understood the desires of Vacaville.

From that modest beginning, we started thinking “big” about Vacaville. Gale encouraged me to think big. With his help in opening some doors within county government, we were relieved of an onerous prior bond issuance which would have made it very difficult to finance any major project in Vacaville. 

With that accomplished, we began to conceive something all the consultants and experts said was a folly — building a hospital in Vacaville. Since it was a “big” idea, Gale was an enthusiastic supporter from the beginning. He helped us develop community support from elected officials in both Vacaville and Fairfield. Without Gale Wilson, then-Vacaville Mayor Bill Carroll and then-City Manager Walt Graham, there is no way NorthBay VacaValley Hospital would have happened.

A side story: Gale wanted us to include, if possible, a large water feature to distinguish the setting of a Vacaville hospital. Our budget was extremely tight, but Gale was stubborn. I finally convinced him we could not afford the water feature. He always seemed sad about that.  

Gale also was instrumental in establishing the neonatal intensive care unit in ICH. When I explained that critically ill newborns were being separated at birth from their mothers and sent to hospitals in San Francisco and Napa, he was very upset. He was a strong advocate of the idea that those babies should stay with their mothers in ICH. We had to overcome much opposition from the other hospitals that questioned whether upstart ICH could operate a quality NICU.

One day I explained to Gale the difficulty in attracting a neonatologist to direct our NICU. What I did not know was that Gale was a friend of a neonatologist who attended his church and who was stationed at David Grant Medical Center. This highly qualified physician would be leaving the Air Force in a year’s time. Once Gale got him interested in ICH’s NICU development, we were able to recruit him as medical director. To this day, the NICU is consistently highly rated for the quality of its care.

Soon we recognized ICH had grown beyond being just a hospital. With the opening of the hospital in Vacaville, we needed to consider reorganization. Gale was very interested, but as usual, it met with some resistance from some quarters. He helped guide a yearlong process with the board, resulting in a holding company being formed to oversee operation of three subsidiary organizations. Again, without his support and leadership, this never would have been possible.

During the nine years I was blessed with Gale as board chair, we completely modernized the operations of ICH, opened a second hospital, started the process of bringing specialized hospital services to Solano County, improved the financial underpinnings of the organization, built two medical office buildings, started a hospice program and completed a corporate reorganization. That is what happens when you have leadership at the board level.

I well remember the day I learned Gale would be leaving his city manager position, and therefore his board membership, to become a missionary for his church. One day when I was between planes at the Dallas-Fort Worth Airport, I heard: “Mr. Gary Passama, you have a message at the red courtesy phone.”

At first I didn’t believe they were saying my name. But then it repeated. With trepidation I found a courtesy phone. Somehow, Gale had tracked me down and wanted to let me know that later that day it would be announced he would be leaving his position with the city. He did not want me to be surprised.

Gale was a visionary leader in many venues. When I suggested to the city that the new street in front of NorthBay Medical Center be named for Gale, it became a fitting tribute. Today it stands as a memorial to a man who wanted his community to be outstanding in every possible way.

Taking A Knife To A Gunfight

In the olden days before Covid-19, my extended family would get together once or twice a year to just catch up with each other in person. These gatherings would consist of at least 40-50 people, all of whom were linked to my now passed parents.

There were groups within this tribal gathering. One large group was relatives who had a law enforcement background. One of my brothers is a retired police officer who no doubt inspired younger family members to consider a career in law enforcement. We have police officers and deputy sheriffs as well as younger college age family members preparing for a career in law enforcement. We even have a retired Superior Court judge in this cohort.

Inevitably the law enforcement tribe will get together at these gatherings to discuss topics of interest. I am not sure what the discussion subjects are. Favorite donut shops? Whatever, our extended family is proud of these relatives dedicated to protecting and helping all citizens, especially in these trying times. These relatives risk their lives everyday for all of us.

There is another tribe in the family. These are relatives who have a connection to healthcare. Even though I am now well established on the beach I proudly include myself in this tribe. We have nurses in the family, a pharmacist and a number of others who are not clinicians but work in healthcare. Being in a helping profession is a source of pride for these tribe members even with the personal risk associated with the pandemic.

A final smaller tribe in the family is that of the educators. Always under appreciated, teachers today are in the midst of controversy surrounding when it will be safe to reopen schools. When schools finally reopen completely, another group of public servants will be taking risks for the rest of us.

The risks my extended family members face became even more real recently when I learned that one of my police officer relatives was sent home from work because of possible exposure to Covid-19. He is now living apart from his family waiting for testing.

Police work involves working with others on a daily basis. There was another officer with whom my relative works who received a phone call from his wife, an ER nurse. The nurse had tested positive for Covid. Immediately, the husband as well as other officers who had been in contact with him were told to isolate. A large number of officers were removed from duty. The husband subsequently began exhibiting possible Covid symptoms.

Hopefully, this story will have a good ending. It’s too soon to tell what the outcome will be. The story does show how this virus can spread even when precautions are taken. My family member who takes his job to protect the public very seriously now finds himself at risk.

The dangers healthcare workers and first responders face everyday remind me of the movie “The Untouchables”. The film contains a memorable bit of advice given by a grizzled G-man (Sean Connery) to a somewhat naive Elliot Ness (Kevin Costner) who is trying to rid Chicago of gangsters:

“You wanna know how you do it? Here’s how, they pull a knife, you pull a gun.”

It seems right now that our front-line helpers are in the same position as those many years ago who were trying to eradicate Chicago of gangsters.

I have read that some people are saying that those among us who are on the front lines of dealing with this vicious virus should be given some kind of medal for the risks they take for the rest of us. I certainly agree that when this is all behind us some form of recognition is due because right now we are sending our helpers to a gunfight armed with a knife.

One More Mountain Dew

It’s been seven weeks since I last put any thoughts to paper in this space. My last item (“Killing Healthcare”) about the financial crisis facing hospitals and medical groups remains unfortunately in the continuing Covid-19 era still relevant. It’s been a depressing time. I really wish I could do something from here on the beach for the great people working in these organizations.

As if to confirm the ongoing crisis, a specialist doctor I know contacted me several weeks ago for advice. He had to close his office per state direction during the first three months of Covid and it devastated his practice financially. A solo practitioner not part of a larger healthcare entity, he was seeking possible salvation by exploring the possibility of giving up his independence. I did what I could to open some doors for him.

Something has changed, however, during the past seven weeks. The use of digital technology has allowed changes to occur in business models including in healthcare.

One modest example—as soon as the ban on visiting physician offices was lifted my primary care doctor’s office reminded me that I was now a little overdue for my annual physical, something I prefer to avoid but always get snared. I dutifully went to my scheduled appointment in an office newly configured and awash in hand sanitizers. I felt a little like Typhoid Mary. I surprised (disappointed?) my doctor by being in good shape for the shape I was in. He ordered some blood tests and said his nurse practitioner would contact me for a video conference about the results.

Video conference? That was new and a week later she and I were viewing each other as we discussed my results. She did seem disappointed that all my lab values were normal, something she says she seldom sees. I felt bad for her. She did get me on my Mountain Dew consumption. I felt good for her.

Video and digital technology seems to be the wave of the future and it is working. My gym is still closed but in the interval I threw away ten years of accumulated trash in the smaller of our two garages and installed a NordicTrack rowing machine and a very trendy Peloton bike which has a somewhat frightening cult following. I now have a nifty home gym. I did promise my wife she can use the rest of the garage to store her vast collection of Christmas decorations but I am hoping she forgets.

Each piece of my home gym equipment has a video component with live and on demand classes. They are fun and demanding and not every instructor is in his or her twenties. Each time I take a class I produce a variety of metrics which are stored for me to review. I can now confirm digitally that I am out of shape which my family has been confirming visually for years.

In both instances, the nature of my interaction has been changed, probably forever. Doctor visits will be changed even when Covid-19 is no longer in the forefront of our minds.

Similarly, I am not sure I will ever need to step into a gym again now that I have a high tech home gym and am a Peloton cult member. My username is “garycal” and sadly I am a member of the Peloton over 60 group. High five me digitally if you see me on the leaderboard (way down on the leaderboard).

So perhaps in this dismal time there is hope and something good will come from the forced changes we have all endured. I believe that to be so. In the meantime I will end this item as I need a Mountain Dew.

Killing Healthcare

Now that the initial surge in COVID-19 cases seems to be flattening, the cost in terms of lives is becoming clearer. Patients in nursing homes seem to be particularly vulnerable.

Caregivers including physicians, nurses and other bedside staff have paid a terrible price in coming down with the disease and sadly some have given their lives. As I indicated a few weeks ago, we need to become wiser in preparing for any new surge in COVID-19 or new virus which may afflict us in the future.

There is another horrible dimension to this pandemic which is only now becoming more apparent. COVID-19 has laid waste to the financial health of our healthcare system. It is killing the organizations we rely upon to care for us when we are sick. This includes integrated healthcare systems, freestanding hospitals and independent medical practices.

This financial carnage became apparent to me this week when I read Sutter Health’s “VOLUNTARY NOTICE OF EVENT RELATED TO COVID-19”. This was an eleven page disclosure to holders of its various bond issues and it paints a very concerning picture of the effects of the pandemic on Sutter’s financial status.

In this document, Sutter outlines the massive decrease in volume of all categories of patient care as well the extraordinary increase in expenses as it prepared for what could have been an overwhelming number of COVID-19 patients. As it has so far turned out, the number of people with the virus requiring hospitalization was not as great as some predicted. Hopefully, that will continue to be the case. Sutter like most health systems and hospitals had to be prepared for the worst.

This perfect storm of decrease in normal patient volume and increase in expense means that for the first quarter of 2020 ending March 30, Sutter had an operating loss of 236 million dollars. That is a staggering figure.

For the month of April, Sutter had an operating loss of 360 million dollars. That is an operating margin of negative 50.57%. These are sobering amounts for a heretofore financially strong health system. Sutter in its disclosure raised the possibility that if this trend continues it might be in violation of one or more of its bond covenants. Sutter’s disclosure statement can be found by going to the following article in the Sacramento Bee and clicking on the link in the article about Sutter: http://www.sacbee.com/article242778051.html .

Sutter is not alone in its now weaken financial condition. Other large health systems are beginning to report similar situations. The Mayo Clinic, as one such example, has suffered massive financial losses as a result of this pandemic. Recovering from this magnitude of financial devastation will be difficult and many may not be able to do so without outside assistance.

I have been afraid to ask my successor at the smaller health system I spent 35 years as CEO what the financial impact of COVID-19 has been. We spent many years building our reserves for a rainy day but this virus is much more than a rainy day. I thought when I retired that I had left my organization in excellent financial shape. I worry about the long term effects of this scourge on healthcare in my community.

There has been some financial relief from the federal government and while appreciated it has not been nearly enough. There is hope that the next round of federal assistance currently being considered by the Congress will result in more financial aid but there are other damaged sectors of the economy competing for the same consideration.

California is considering how it might assist healthcare providers. Whether any significant aid is possible in light of the state’s burgeoning deficit due to COVID-19 is problematical.

I fear that if there is a second surge of this scourge later this year and it is recommended that we adopt the same closure of “elective” services, we will kill in a financial sense healthcare providers. Hopefully, we have learned lessons from the last few months which will allow a more nuanced approach to containing the virus while allowing healthcare providers to also survive.

Why Do We Have Hospitals—Revisited

National Nurses Week begins on May 6 as it does every year. The theme this year is Compassion/Expertise/Trust. Honoring the nursing profession is especially meaningful this year given the role nurses have played in the continuing struggle against the Covid-19 virus. Nurses are part of a team and their role is pivotal. Last year at this time I wrote and published in this space some thoughts about the nursing profession and how it affected my perspective on patient care throughout my career. Those thoughts from last year are I believe worth repeating and they follow.

WHY DO WE HAVE HOSPITALS?

Many years ago when I was newly promoted to Chief Operating Officer of a large hospital in Berkeley, I was asked by the Chief Nursing Officer who had been my peer but was now my subordinate this question:
Why do we have hospitals?


I offered several fumbling answers, each of which she told me was wrong. I was beginning to think she was trying to put newly promoted me in my place when she gave me the correct answer: Because patients need nursing care. That’s the reason they are admitted.


She was right then and she would still be right today. The fundamental reason why patients are in the hospital is because after everyone else has had a go at them, they require the care and attention of a nurse to recover.


While nursing care continues to become more dependent on technology and requires increasingly more education and training, it still is at its core a one-to-one relationship with the patient.


My introduction to the profession of nursing took place as part of my graduate education. I was in the minority of my graduate program cohort in that I had no clinical background. That’s how I found myself doing the duties of a nurse’s aide in a Bay Area hospital for four months before my first semester.


I worked alongside nurses and saw them using both high-tech and more importantly high touch in their care of patients. One situation I will never forget was watching late one night from across the intensive care unit a nurse brushing the hair of a seriously ill teen age girl who was crying, offering her comfort with her words. I watched that girl get calm and for the first time understood the importance of nursing.


Another time I was working in the emergency service when an elderly woman in cardiac arrest was brought in. She had been on a passenger train when she fell ill. My job was to fetch things for the doctors and nurses as they tried to revive her to no avail. When the patient was declared dead, one of the nurses asked me to remain in the room with her and the patient. She told me that what we were about to do was as important as all the efforts to save the patient’s life. Our job was to prepare the patient to be seen by her husband who was waiting elsewhere in the hospital. She said it was important that he see his wife as he remembered her and not as someone with tubes and other equipment connected to her. That nurse taught me that caring for the patient sometimes means caring for others as well.


I saw other nursing interventions that continue to move me emotionally even many years later. Often, it seems that the only person taking the time to truly understand the concerns of patients is the nurse.


I am proud that there are now nurses in my family. It is a great profession with many avenues of opportunity. Whenever I can, I encourage young people to explore nursing as a career.


While the nursing profession now has many important roles outside the hospital, I remain partial to hospital nurses because, after all, that’s why we have hospitals.


May 6 is National Nurses Day and that week is National Nurses Week. If you know a nurse, give her or him a thank-you for what they do. They deserve the recognition.

Becoming Wiser

“Any fool can know. The point is to understand.” Albert Einstein

Since COVID-19 began affecting my life, this fool has resisted adding to the items I have posted on this site. Instead, I have tried to understand the dynamics of this interesting and disconcerting time.

My life has changed and not for the better. It has been weeks since I have seen my seven grandchildren even though they live close by. I have been told over and over again in the media that because I am over a certain age I am fragile. I think the word is stamped on my forehead.

Because my daily exercise must now come from fast walks around the neighborhood rather than in a gym, I have to watch out for rattlesnakes in my path while I try to not be fragile. I am considering getting a Peloton exercise bike but the video instructors seem dauntingly fit and I am not.

I get excited when my wife and I go out to lunch occasionally by going through the drive-thru at Chik-fil-A and then finding a remote spot in the parking lot to eat. Sort of like high school.

Things have changed dramatically as well in healthcare. Politicians no longer seem concerned about price transparency, an issue I have always thought was more hype than real at least here in California. Now the number of ventilators and the supply of personal protective equipment consumes elected leaders.

Governors are elbowing each other to get on cable news programs. You can see New York tough and California cool everyday. Other healthcare related issues once thought to be important have disappeared because of a virus.

Hospitals and the people who work within them are now hailed by the pols as heroes and heroines rather than the source of wasted expenditures. They have always been worthy of praise but maybe COVID-19 is helping people to remember that. I hope that memory lingers on after the pandemic itself becomes a memory.

A pandemic reorients viewpoints and issue priorities. Maybe the fools are beginning to understand the fragility of healthcare institutions and public health. One can hope.

I have come to understand some issues that we within healthcare must become wiser about. We have allowed ourselves to worship without regard to consequences at the altar of reducing costs. That is how we find ourselves at the mercy of a totalitarian country which produces most of the basic supplies like masks and gowns used in healthcare facilities. We need to be willing to spend a little more so that other countries including our own are encouraged to produce such necessities. That’s called spreading the risk.

We need to reconsider in hospitals how staffing patterns are determined. There has been great pressure from the politicians and others to keep staffing at a minimum level consistent with patient need. This works until demand for services greatly increases and suddenly you have more patients than staff to care for them. We will need to build more flexibility to meet staffing needs in the next pandemic.

Becoming wiser will not come without costs. The current COVID-19 situation has laid waste to even financially strong healthcare organizations. When you hear about layoffs in the midst of the pandemic at organizations like Mayo Clinic, you know that things are bad. Will smaller healthcare organizations be able to survive?

Which brings me to a quotation by John Ruskin I have often written about and which hung on the walls of my office during my career:

“There is hardly anything in the world that some man cannot make a little worse and sell a little cheaper, and the people who consider price only are this man’s lawful prey.”

Here’s to becoming wiser.

Women of Influence

I was reading my local Sunday newspaper this weekend while on the beach. Reading the Sunday newspaper use to take at least one hour but now I can do it in twenty minutes or less. Change has wreaked havoc on this particular mode of communication.

This particular Sunday, however, there was an insert recognizing local “Women of Influence” complete with photos and brief biographies of each woman. My old organization’s three female senior managers were among the honorees. I was very happy to see that. Each has immense responsibility and was worthy of that recognition. As I wrote to them, the only change I would have made would be to call them “People of Influence”.

Reading about my former colleagues got me to thinking about the female senior managers who had influence on me or whose skills as managers impressed me and made my job as CEO easier.

I first thought of a woman who was an Assistant Administrator (now we call them Vice Presidents) at the hospital where I had my first administrative position. She was a graceful, experienced manager who was old enough to be my mother. I was a twenty-three year old senior manager (in those days it was possible to be hired into a senior management position right out of grad school) who had more opinions than wisdom. She tempered my opinionated self even though she was technically my peer.

One day, I was carrying on about an assistant administrator at the rival hospital in Berkeley whom I did not like simply because he was at the rival hospital. That made sense to me but not to her. She brought me up short and told me about how community-oriented that person was and what a great person of integrity he was. That person I did not like later became a colleague and even later a valued consultant to me. He remains a friend to this day. Thank-you, Margaret, for educating this ignorant young person.

A few years later, I became the chief operating officer of that hospital and the nursing function was part of my realm. We had just recruited a new chief nursing officer who had a strong academic background and even stronger views about what a professional nurse should be. She challenged me, not in a disrespectful way, to learn about the nursing profession. In a story I have told many times, she early on asked me why are people admitted to hospitals? I fumbled with my answers, finally saying it was a place for doctors to do their work. Wrong answer, she emphatically replied. Patients are admitted to hospitals because they require nursing care. As I thought about it, I realized she was right. One more woman of influence in my professional life. Thank-you, Geraldine.

When I became CEO at the place where I would spend almost thirty-six years, I brought the lessons I had learned in Berkeley. I was blessed over the years at the new organization with strong managers of both genders, most of whom did not hesitate to confront me if they thought I was wrong about something. Given my opinionated ways, there were many such discussions.

That first year as CEO, I had only one senior manager who was female. She was not particularly welcoming as she had hoped one of the other existing seniors managers would be named CEO by the board rather than an outsider. She was tough on the me, making it clear I would not have a reserved parking space. Never having had one it was no loss although I wondered who was the CEO in this relationship. As we developed a relationship which would always be a little rocky, I appreciated the zeal she brought to her job and the loyalty she earned from others. Thank-you, Alison for making sure my head size did not grow.

As the years went by and my organization grew, so did the number of senior managers until one day, I realized that half of my senior managers were female which was at the time unusual. It was not because I was somehow enlightened. It was simply a process of elimination during the recruitment process—the best got the job.

That group of female senior managers were the key to what became an explosive era of growth. In the process, they became role models for other women in the organization. Most had a long tenure; two were with me for thirty years or more and they were all fantastic managers. Thank-you Deborah, Elnora, Kathy, Margy, Bridgit and Pam.

The three female senior managers recognized this week joined the organization in 2014-15. They inherited a culture that they have made better. They walk in the shoes of some great senior managers of both genders but each in her own way is putting her stamp on the organization. Thank-you Aimee, Traci and Nicole.

When I read about the glass ceiling women face in other industries, I have to laugh. How backward is it to think that women are not as capable as men? Healthcare proves that wrong everyday.