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Recommendations 11

• R1
  The Board must terminate AHM, with cause, based on the fact that the hospital is near bankruptcy under their Management. The Medical Staff agrees with the recommendation of the Grand Jury. This is what we recommended to the Board in a closed session on May 9, 2007. The result was that AHM retaliated against the Medical Staff with public defamation and anti-competitive behavior The District's counsel attempted to defend AHM by noting that it was engaged by the District to initiate a transition with $60,000 in the bank. But that is a completely disingenuous statement. He knows. That was before the District had any control over the hospital. Once the keys to the "hen house" were given to the "fox" on January 1, 2006, the hospital had millions of dollars in the accounts receivable and in the bank, which were brought in as a result of a good "working relationship with the Doctors" as Mr. Fallon stated to the outgoing LifePoint CEO. It is true that under AHM the hospital operated profitably during the first year. But that was largely due to the hard work of the Medical Staff. Concerns were raised by members of the Medical Staff even during that profitable year that AHM had a bad habit of spending money quickly while lowering the quality of services. When admissions fell, AHM was unwilling to shave its top-heavy administration and when the Board was publicly asked to consider restructuring administrative costs in order to keep surgery and obstetrics open, Mr. Copple responded stating that that topic was not to be considered during that meeting as it was not agendized. AHM has successfully waged a publicity campaign against the doctors in this town, having found a willing accomplice in a newspaper editor who was biased against doctors in the first place and who historically poorly investigates matters he writes so passionately about. AHM has consistently leaked confidential information to the press to further its strategy of blaming the doctors to cover up for their poor managerial skills, and the fact that they were the cause of the rift between the two parties in the first place. AHM has been pushing to the hospital toward critical access status, a move that will pay the hospital better as long as census is kept low but a move that would also, by necessity, limit the services that the hospital would offer. AHM has repeatedly discussed wanting to close obstetric services, and that is probably why they have not paid the OB Doctor for a year hoping that he would leave too. AHM would rather circumvent the rules of the hospital and pay hundreds of thousands of dollars in attorneys' fees than invest in the hospital. During the recent open house, the doors to the CAT scan were closed to the public because the machine was down, once again. It took a week and a half to get it running again, requiring numerous patients to be transferred from our hospital's emergency room to other emergency rooms and hospitals to undergo CAT scans. It was only after receiving a complaint letter from the Chief of Staff that they brought in a portable CAT scan machine for temporary back up. This failure to timely fix this problem cost the hospital tens of thousands of potential dollars in lost admissions and studies. The bottom line is that it is time for AHM to go. Re-evaluate the present staff's wage rate structure and reduce them to be more in line with hospitals of similar size and location. For years, this hospital was run by for-profit companies that limited pay to the nurses. Yet, the hospital was able to maintain staffing during those years and would likely be able to continue to do the same should it cut back some on the wages to its nursing staff. Unfortunately, the hospital has come full circle and has disciplined nurses to the point where they would rather quit, than run the risk of having their licenses in jeopardy by being reported to the nursing Board. Even forgetting to clock in after returning from lunch is apparently now cause for discipline. The hospital is now staffed with more traveling nurses than local nurses. Nurses are also being threatened not to talk to the Medical Staff for fear of losing their jobs (Attachment D). Of course traveling nurses are immune from the discipline the hospital exerts on its local staff. Unfortunately, the hospital pays even more for traveling nurses than it does for the higher wages that the Grand Jury is concerned about.
• R2
  We disagree with Mr. Fallon's assertion that LifePoint was paid $1.8 million per year. Once it decided to give up Palo Verde Hospital in March of 2005 due to the increased expense for retrofitting and severe decrease in revenues, LifePoint began showing a $79,000 to $155,000 monthly management fee for bookkeeping purposes, only for the last few months. Current Board member Steve Montgomery did not deny this when asked publicly. He was previously on the Board when LifePoint managed the Hospital and he has knowledge of these transactions. In fact, the total charged in this fashion was only $855,000 for the year, not $1.8 million (Attachment I). It must be noted that the Board has repeatedly refused to meet directly with the Medical
• R3
  The Board President must appoint citizens from the Blythe community who want to be involved and have skills to serve on advisory, standing, or ad-hoc committees. This community involvement should enhance the capabilities and the functioning of the Board. We agree with this recommendation and we cannot understand the District's opposition to it. In our collective experience, it is quite commonplace for hospital administrations to hold periodic meetings with heads of the community to brainstorm. Whether it is to come up with a mission statement for the hospital or to set goals for the coming year, five years, and ten years, this is a valuable resource which is not being tapped. The hospital actually did this in the past when it suited it purposes. A "blue ribbon committee" was set up when the hospital was considering what kind of work could be done toward building a new hospital. They should do more of that. Expert input from the community can be invaluable to the Board to sense community needs. The Board should be responsive to the community. In addition to this, the Medical Staff feels that the Board should annually assess itself. It should set personal goals for the coming year and assess how well it has done. It should assess how open they are to community concerns, how effective they are toward understanding the budget and auditing process, and how effective they are at providing guidance to the CEO. This assessment should be reported in open session. They should also perform annual assessments of the performance of the CEO in a similar manner. Instead of insulating themselves from the Medical Staff, they need to include the Medical Staff in their closed sessions when appropriate to better understand the Medical Staff perspective before they make decisions which impact the institution. Against their own Bylaw instruction regarding delegating credentialing to the Medical Staff, the Board holds closed session meetings first and makes decisions on credentialing, and then later in the public meeting gets to hear the Medical Executive Report.
• R4
  Members of the Board must understand and follow the By-Laws, including the California Health and Safety Code, Division 23. In his response to the Grand Jury Report, the District's counsel paid lip service to this recommendation stating that that the Board will follow this advice while at the same time directing the Board to not follow the Medical Staff Bylaws. This was what led to the recent litigation. For some reason, some of the Board members apparently feel that because they have the ultimate authority over what happens at the hospital, they can disregard whatever rules they need to. The Joint Commission would not look favorably on such behavior. The Medical Staff would appreciate it if the Board would stick to the rules that they agreed to just two years ago.
• R5
  Complaints registered by the MEC must be made in writing and submitted to AHM and the Board for review and disposition. AHM must respond in writing with a positive approach to solving the problems in no more than seven calendar days after submission. Should any conflict arise, the Board will resolve the conflict. The Medical Staff is agreeable to this. However, AHM should be sanctioned in some manner if these reports are leaked to the press for propaganda tools, or used to instigate a retaliatory response from the staff named in the complaint against us, as it has already done. With the limited free time that we have to attend to these issues, verbal concerns should not be ignored just because it was not in a written form. Could you imagine a Police Officer not stopping a fight because he was waiting for a written complaint? We are concerned about the mechanism that the Board will use to mediate the differences between AHM and the Board, particularly since they have refused to meet in good faith with the Medical Staff. The Medical Staff is agreeable to mediation with the assistance of a mutually agreeable mediator. We would be more pleased if the Board, in light of its' history of not acting in good faith, were to agree in principle to respect the decision of the mediator. Up to this point, most of the time written complaints fall on deaf ears (Attachment E). On June 3, 2008, Dr. Sahlolbei, Chief of Staff made a written complaint to Mr. Flood, CEO regarding the issue of CRNA proctoring with some suggestions in a friendly letter. In response, the board passed a resolution waving the mandatory initial proctoring on June 5, 2008, violating the Medical Staff Bylaws. This resulted in the court issuing an injunction forcing the Hospital to proctor CRNAs "as required by the Bylaws", which at the same time allows CRNA to work in an emergency situation without proctor; and there was no need to close the Surgery/OB departments (Attachment F).
• R6
  Modify the MEC By-laws to allow a Hospitalist, "A physician who specializes in seeing and treating other physicians' hospitalized patients in order to minimize the number of hospital visits by the patients' regular physician" to admit patients, a practice common in other hospitals. The Medical Staff is not opposed to the concept of a hospitalist. The Bylaws currently do not prohibit the hiring or credentialing of a hospitalist. However, as the majority of our members tend to their own patients, there would not be enough work for a hospitalist. We are also concerned that it might lead to inappropriate admission and charges.
• R7
  Amend the future administrative contracts to add performance targets that must be achieved prior to ranting any increase in compensation. The Medical Staff agrees with the Grand Jury on this recommendation. It makes no sense to grant unconditional raises in compensation to a management group which monthly states that they are losing money. The Board should, as previously stated, set goals for the CEO and discuss increases in compensation should goals be met. To reduce costs immediately, the Board should consider eliminating the position of "assistant to the CEO." It is redundant and unnecessary. The CEO should be able to attend to all the matters that a hospital this small should encounter. Also, the person who filled that position is presently filling in as the human resource director of the hospital and as such she is grossly overpaid for the work she is doing; which seems to be limited to hiring travelling nurses and firing local nurses. The hospital would be better served in our opinion by looking for a human resource director who would accept the salary commensurate with that position, and a director who does not fire local nurses to further AHM agenda. It is also our recommendation that any new positions for hire by the hospital be accepted by the Board before they are hired and before they start receiving a salary from AHM. The Board should be the body deciding if a new position is necessary and what the salary should be according to a pre- determined pay schedule based on the position and experience. AHM should not be hiring people and saddling the district with additional employees without the direction of the Board. This should apply to consultants as well. All new hires and positions should correlate with the mission of the hospital and be working toward the goals that the Board has set for itself. In the September 2008 Board meeting after Dr. Sahlolbei repeatedly had complained that the Board is not acting independent of AHM, was not transparent, had violated its own Bylaws, and had ignored its policy on contracts, Mr. Fallon claimed that he keeps the Board President Copple informed. Yet, Mr. Copple himself is not the Board and the Board and the public needs to be informed before contracts are signed.
• R8
  The PVHD By-laws need to include a policy that the Board of Director's agenda packets must be prepared and distributed to the five-member Board a minimum of three days prior to a Board meeting. This allows time for the members to study critical data and request any additional information, if necessary. This may actually be the policy of the District now, but it is not adhered to. Also, the Board should not amend their agendas at the time of the meeting with issues not of an emergent basis as it violates the spirit of the Brown Act. We do not recall any time that the Board members asked for correction of any minutes except in September of 2007 which were approved without the correction, which was against the Board's Bylaws. AHM is not perfect in reporting the minutes and the Board has been asleep at the wheel on more than one occasion. Dr. Sahlolbei informed the Board and Derek Copple and documented the major action, motions, reports and statements that were misrepresented in the Board minutes compared the minutes with the audio recording, but his concerns were dismissed (Attachment G). Prior to the monthly Board meeting, the Board should be required to reasonably review in detail the PVH budgets and financial performance with the hospital's Financial Officer, and take necessary action. Prior to monthly Board meeting, the Board must routinely review in detail the PVII budgets and financial performance with the hospital's Financial Officer, and take necessary action. We agree with this recommendation. Major discrepancies like the $1,700,000 loss in FY 2007 reported in financial reports as opposed to a $700,000 gain for the same year according to the audit are not discussed in public. The CFO must meet with individual board members without AHM presence to explain the true financial reports.
• R9
  The hospital could have made millions of dollars over the last 18 months as it did in the first 18 months, but instead, by repeating the mantra that "they are not going to be told by the Medical Staff what to do," even if it can improve the quality of patient care, they are driving this hospital down and forcing it to critically downsize services.
• R10
  Reopen the Obstetrics Department and hire qualified personnel to staff it. The Obstetrics Department is reopened. There was an incident last month where the hospital pressured an Ob nurse to work on the medical surgical floor. The nurse did not feel that she was qualified doing so and expressed her reluctance to work there without proper training and supervision, but she was fired by the hospital. Good OB nurses are crucial for the OB department, and they are extremely hard to come across and should be protected from such discipline.
• R11
  The Board should: Resolve the conflict among the Board, a. AHM, and the MEC; and The Medical Staff does not understand how the Board can claim that it has made any attempt to settle or resolve issues with the Medical Staff when they repeatedly refused to meet with us. In a meeting mediated by Senator Ducheny, we agreed to have a mutually selected mediator assist us with resolving our disagreement, but AHM backed out after we agreed on the mediator. Also, the Board has become heavy handed in its dealing with the Medical Staff, demanding credentialing to occur by deadlines it never previously required. b. Reopen the surgical services, thus giving the states' prisons a nearby hospital. The Medical Staff agrees that the surgical services need to remain open at any cost as it will and has saved lives. The Medical Staff had been asking for months for the department to reopen over repeated claims by the administration that is would open in January, then February, then March and so on. Mr. Fallon threatened to close OB and Surgery department again (Attachment H) for financial difficulties, but in the August Board meeting he had stated that the revenues are up with Surgery and OB reopened; which one is the truth?