The League of Voluntary Hospitals is the association of non-profit hospitals in New York. It, along with the hospital workers union, SEIU, long ago established something called the Job Security Fund. Its purpose was to cushion workers from hospital layoffs by providing retraining and placement in another member hospital during hard times. It has been a great success, but even it has struggled during the recent wave of hospital consolidations and closings in New York. Shrinkage drains the grease that lubricates the machine.
What does this have to do with Gov. Juan F. Luis Hospital on St. Croix? Nothing, and that is the problem. Health care in our country is going through a painful transition, and hospitals face wrenching changes. Consolidate, develop integrated networks, improve quality and outcomes, contain costs and maximize revenues. All in an environment of great complexity and uncertainty.
These challenges and the new systems that are emerging are not a good fit for small communities with stand-alone hospitals. They are an especially bad fit for those that function as both a major health provider and a principal source of jobs in the community. And, as events in New York and elsewhere have clearly demonstrated, the more politics are involved in hospital decision-making and operations, the worse the outcomes.
Health care delivery is extraordinarily complex in our country. That is one of our problems. I once asked a very knowledgeable person how many people in New York State (population 20 million) really understood Medicaid. She put the number at under 50. The same applies to the St. Croix and St. Thomas hospitals, when we are talking about hospital financial management. Add to this reality the fact that the current crisis is not only about current operations, but also what to do about an overhang of long-standing debt.
The devil is in the details, so this is not going to one of those “here’s what you should do” pronouncements. My guess is that the number of people in the territory who understand the real choices can be counted on two hands, and one of those, Mr. Nelson, is leaving his post. Instead, based on experience in similar situations, here is what I believe is a framework for finding the best possible outcome, which is to say, the least worst one.
See the situation as it is: More than most people, Virgin Islanders have a habit of believing that there will always be one more reprieve, that the last warning is actually the second to last one. And they have been let off the hook often enough for this belief to be grounded in reality. But it may not be this time. Hospitals on the mainland that held onto this belief have been closed or taken over. It is important to see the situation as it is, rather than as we would like it to be, and to face reality when defining what the realistic choices are. In particular, what reason is there to expect that we will do something now that we were unable to do in the past?
Short term/long term: Part of confronting reality is separating short and long-term needs and to make sure that the first doesn’t fatally compromise the second. This is very difficult to do when you are under the gun, but it is essential.
Pulling together: Institutions that successfully survive crises of this nature are ones in which all of the “stakeholders” come together around a shared vision of what they want to achieve and agree upon the steps they have to take, as painful as those might be. When you look at failures, you almost invariably see a pattern of mistrust, infighting and refusal to submerge individual interests for the common good. If there are sacrifices of any kind, the pattern in failures is, “You go first.” Getting over this hurdle will be a heavy lift for Virgin Islanders.
A starting point would be to adopt a principle of not looking backward to assign blame and, instead, focusing on the future to solve problems. There is a story of two baseball managers, one successful, the other not so much. The first one spent his time in the third inning thinking about what he would do in the seventh inning. The unsuccessful one spent his time in the seventh inning figuring out who screwed up in the third inning. Looking forward and problem-solving are essential to working your way out of situations like this one.
Choices: There are always choices. In situations like this, they are usually the choice between bad and worse, at least in the short run. It is always worth making these choices, even though no one will ever give you credit, and there will always be someone who will pretend that there was really a wonderful choice that only he or she saw. Blaming and finger-pointing are the kiss of death.
Change or die: On a scale for measuring change resistance, Virgin Islanders are on the high end – a luxury the territory can no longer afford. Hospitals that have closed in New York did so for a number of reasons, some beyond their control, but one that was controllable was getting beyond a refusal or inability to change. Right to the end, they believed that they could use one of their lifelines or phone a friend to avoid making the changes that were essential to survival. They were wrong, and, at some point, there was no last chance.
These essential changes are always and everywhere clinical, political and organizational. On the clinical side, they almost certainly involve services integration and coordination, expansion of telemedicine and making the best of the painful transition to electronic medical records. Politically, they will require getting politics out of the running of the hospital to the maximum extent possible, another heavy lift.
One political change involves the acceptance of outsiders. When we look around the country, we can see that the most successful places are the ones that welcome outsiders. For the territory, there are two subtexts here. The first is that there is not enough local managerial talent, at least now, to successfully run a major health care facility in the current environment. And, it would be a bad thing to be seen as a place that is career-damaging for outsiders. The second subtext relates to Descartes’ maxim that “The most corrupting lies are problems misstated.” It would be unfortunate – and inaccurate – if the hospital’s problems were defined as screw-ups by an outsider.
Finally, there is the organizational dimension. The principle here is straightforward and best stated by the author Patrick Lencioni: “Organizational health will one day surpass all other disciplines as the greatest opportunity for improvement and competitive advantage.” When we step back and look at any organization, the power of this message becomes crystal clear.
The territory, St. Croix in particular, has taken a number of hits in recent years; recession, Hovensa and now the threat to the future of the hospital. Most of these were beyond the control of the Virgin Islands. In situations like this, there is always the danger of compounding the damage with self-inflicted wounds. Avoiding them should be a top priority.
