(Artvoice  5 July 2000)
Children’s Hospital: What Now?

By Bruce Jackson
 

HIGH ON HIGH STREET

The Children’s Hospital Ad Hoc Committee--appointed in September 1999 by Kaleida Health to recommend whether to rehabilitate Children’s Hospital at its present location on Bryant Street or to build an entirely new hospital for children linked by an upper-story bridge to Buffalo General Hospital on High Street--finished its work last Wednesday afternoon.

SalAlfiero, former chairman of both the Children’s Hospital and Kaleida Health boards and present member of both the Kaleida board and the Ad Hoc Committee, announced the Committee’s choice. He said that “it is our belief based on visits to other sites in similar type cities as Buffalo that a children’s hospital will be the anchor to a world-class medical corridor which will spur economic deveopment, attract additional research funding, and enhance the image of the Buffalo-Niagara region.”

There were several protective conditions grouped under the rubric “conditions precedent” (about which more below), but the bottom line was: move the entire operation to High Street and don’t just walk away from an empty building on Bryant Street. Alfiero said there would be a “steering committee that will oversee this process because there will be conditions that have to be fulfilled before turning the first spade of dirt.”

Theodore “Tip” Putnam, Children’s Hospital pediatrician and former president of the Children’s medical staff, spoke at some length about the Ad Hoc Committee’s vote. Putnam was a member of the Physician’s Coalition, so his unqualified endorsement of the vote for the move was particularly significant:

I’d like to elaborate on some of the medical justifications in support of our recommendation. First and foremost, the recommendation will enhance health care and clinical outcomes for children, women and families. It should and will create a synergistic environment for collaborative research, both clinical and basic, between pediatric and adult physicians and provide access to advanced technology. By having all treatment programs on one campus it will reduce the fragmentation that currently exists in the care of the high risk obstetrical patients and pediatric oncology patients. The High Street option will optimize the care of adult survivors of pediatric diseases. As these individuals become adults, many of them have significant medical problems and require the input of adult care physicians who by necessity have to coordinate with their pediatric colleagues to ensure successful outcomes. This can best be served on a single campus. I don’t think there is any doubt that a new state-of-the-art children’s hospital anchoring a world class corridor will also help us to attract and retain more outstanding medical talent. A new children’s hospital will become a desirable medical destination for all types of health care professionals.
Patty Duffner, Children’s Hospital pediatric neurologist and another former president of the medical staff, echoed Putnam’s comments and talked about her own excitement at the possible move:
There’s a lot of issues out there that people I don’t think have been educated about. We have basically throughout this process not talked about these issues because we signed something in the beginning saying the work of the committee was private. But now I think as people begin to explore all these issues they’ll begin to understand the real excitement we all have about the potential of moving. Being next to adult facilities is not a negative thing, it could be very exciting. Our older patients, the ones who have aged out but who still have pediatric diseases, I’d like some of the help of my adult colleagues to handle some of those patients. The research–to be right next to Roswell, to work with some of the other people in the other institutions, it could be so exciting! It could just turn this whole medical community around, and I think as we start thinking about the positive aspects, a lot of these questions–questions about this square foot and that square foot–may fade into the background.
Sal Alfiero had the last statement:
The very questions that are being raised about how many square feet and can it go there and will it make economic sense and so forth, these are the questions that are about to be answered through this next step. What is this step? The step is to form the steering committee, which will be comprised of members of different constituencies who will make sure that the proper input is made into the specific design and engineering of the facility. While the questions can’t be answered yet as to whether there’s enough space, whether you end up with a building that’s 6000 square feet in footprint and has to go 28 stories high in order to get the necessary square footage, that’s something that only the design phase will be able to tell us. And what we’re doing is, we’re spending the money in order to design and engineer this thing with the input from the various constituencies to ensure and to make sure or assure the feasibility, the physical feasibility of it, to make sure that it can be done properly to carry out the necessary missions that will be outlined and detailed. And secondly to be able to cost it out, to determine whether we can afford it or not. That’s what this is about.


KALEIDA RATIFIES

Four hours later, Kaleida Health board chairman Thomas Beecher told a small group of reporters that the Kaleida board had voted unanimously to adopt the Ad Hoc Committee’s report and that the feasibility study of the High Street project by the soon-to-be-named steering committee would soon begin.

He read off a resolution that, save for one phrase, was an unremarkable ratification of the Ad Hoc Committee report:

Whereas, in September 1999 the board of directors of Kaleida Health appointed the Children’s Hospital of Buffalo Ad Hoc Committee to deliver an opinion to the board of directors of Kaleida Health recommending the best site to deliver pediatric care and high risk obstetrical care for the citizens of Western New York, and to advance our support of the University at Buffalo’s medical education and research programs, and to educate the community about the process being used in the committee’s recommendation,

and whereas the Ad Hoc Committee has completed its charge and delivered its final report and recommendation to the Board on June 28, 2000,

and whereas the Board accepts the report of the Ad Hoc Committee and extends to each of the  members of the Committee its sincere appreciation for many hours of work contributing to this effort and for their diligence and commitment  to accomplishing a challenging task, in the interest of optimizing the delivery of high quality health care in Western New York and beyond,

now, therefore, it is hereby resolved, that the Kaleida Health hereby adopts the recommendation of the Children’s Hospital Ad Hoc Committee to locate a new Children’s Hospital as part of a High Street medical corridor, subject to the conditions precedent articulated by the Ad Hoc Committee, and delineated on attachment A hereto, subject to ongoing review, oversight, and final requisite approvals by this board,

and it is further resolved, that the officers of Kaleida Health be, and each hereby is authorized and directed to take such actions as may be necessary and appropriate to effectuate the foregoing resolution.

All the wherefores and therefores and whereases are saying something quite simple: we thank the Committee for its work and we accept their recommendation without question or qualification.
 

THE UB EXCEPTION

The one curious phrase in that resolution is the one that goes “and to advance our support of the University at Buffalo’s medical education.” Why should Kaleida Health fret about UB’s designs in the course of setting its own sails for future voyages? Did any hospital in town ever before give a hoot about what UB did or wanted?

Probably not, but times have changed. The whole structure of medical service delivery and medical education and medical money and medical power has changed.

In the current fiscal climate, Kaleida needs Children’s more than Children’s needs Kaleida, UB needs them both and both of them need UB. There’s a lot of talk about the synergy that will happen if and when Children’s moves into the so-called High Street Medical Corridor, but it’s important to bear in mind that two of the key players on High Street–Roswell Park and Hauptman-Woodward Medical Research Institute–are not part of Kaleida and would probably fight to the death to keep from becoming part of Kaleida. The only thing Kaleida has on High Street right now is Buffalo General, a city hospital much like any other, and its own very fine office around the corner and a block south. The medical corridor may indeed become a synergistic site, but unless Children’s moves there Kaleida doesn’t have anything out of the ordinary to put on the table.

UB does. It is the other key money player in all of this. Just like Kaleida, it has internal needs that lead it to want a concentration of principal medical operations in one place. For a long time the UB medical school existed more as an idea and an intellectual collaboration than a physical entity: med students did their basic classes at UB, but all their clinical work in the latter part of their medical training and their residencies took place at a dozen sites around town and the key segment of the faculty served on a volunteer basis.

That worked well enough in the financial scene of a few decades ago, but in recent years–with the huge changes in funding and in Buffalo’s population–the UB administration grew less and less comfortable with that willy-nilly system. Michael Bernardino, UB’s vice president for health affairs, was a highly-regarded research radiologist before he moved into medical administration and got an MBA.. He was brought here not just because he understands medical education–UB has several of people who understand medical education perfectly well–but because he also understands money.

Moving Children’s to High Street, Bernardino says, “gives this community a first class pediatric facility.  One that it can be proud of.  One that can be competitive on a national scale.  The other competition is not Buffalo, contrary to what most people think around here, where they want to fight with the next person on the next block.  The competition is regional facilities and national facilities, and we want to build pediatrics into a nationally known, top-ranked facility. The potential is there, if we do this.... It would give this community a health science complex that would compete with anything anywhere in the country. We could compete with anywhere.  And it’s about time that we do things that make this city competitive.”
 Collecting a full range of clinical, research, and teaching capabilities in one six-block area would do something more: it would give UB, for the first time, a real medical campus.
 

CONDITIONS PRECEDENT

The Ad Hoc Committee didn’t simply roll over and give the Kaleida board and the University at Buffalo a blank check. The Committee set down several very specific conditions—their conditions precedent--- before any construction begins.

“Conditions precedent” has the ring of a medieval jousting afternoon (lions rampant and such) but it has a specific meaning in contract law. It means certain things much be done before anything else we’re talking about can take place. In this instance, it means a list of conditions that must be fulfilled or otherwise honorably dealt with before a Kaleida spade slices the earth on High Street.

It is entirely possible that the Kaleida board or the Kaleida management could decide to weasel out of those conditions, or that they could hope the public has a short memory and no list of those conditions to cite. They might, at the end of the steering committee process, say, “Well, we can meet 80% of the Ad Hoc Committee’s conditions precedent and that’s a lot, so we’re going ahead with construction.”

If that came about I’d expect that at least some members of the Ad Hoc Committee would howl in rage, and so would some members of the steering committee, since their personal and professional honor and reputations would be at stake. If these conditions precedent have any meaning at all, every member of both those committees has an interest in seeing them met. They can’t just step back and say, “Well, we’ll leave it to the Kaleida Board.” If they do that, then they’ll have a devil of a time denying the inevitable charges that they were Kaleida pawns all along.

These are the conditions precedent listed in the Executive Summary of the Ad Hoc Committee’s report:

These conditions are unequivocal; and are essential to the  project's success. Among these conditions are:

The commission of a multidisciplinary Steering Committee comprised of pediatricians,  obstetricians/gynecologists, nurses, Kaleida staff, community leaders, parents and others to oversee  all phases of the project, including architectural planning.

The immediate improvement of the Bryant Street facility, including both the Neonatal Intensive Care  Unit and Emergency Room.

The planning and design of a free-standing and full-service hospital that avoids integrating pediatric  clinical services with adult clinical services.

The development of a dedicated pediatric pharmacy component, staffed by one or more pediatric  pharmacists, within a single pharmacy.

The inclusion of sufficient, convenient physician office and research space.

The development of a detailed financial plan and the securing of financing commitments, including  one from the University at Buffalo.

The maintenance and enhancement of the quality of care at the Bryant Street location during the  planning and construction process.

The development of a comprehensive "re-use" plan for the current Bryant Street site.


OPEN QUESTIONS

What happens if Kaleida chooses to disregard those conditions? Who or what is the watchdog? Perhaps that’s specified in the full version of the Ad Hoc Committee report, which Kaleida chairman John Friedlander’s office promised to let us see but didn’t. From all we’ve been able to discern thus far, the Ad Hoc Committee trusted Kaleida enough not to feel the need to write such an enforcement clause.

Some inconsistencies and problems are already obvious. At their brief press conference after announcing their unanimous adoption of the Ad Hoc Committee’s recommendation, Kaleida board members said that the final decision on reuse of the Bryant facility won’t be made until it’s time to reuse it, at least six or seven years from now. So how can the steering committee possibly answer that question in the 18-24 months Friedlander says will be its term? By the time we know what’s going to happen to the Bryant facility, the new building will be up and occupied. There’s no reverse button in real life. As Robert Moses, the greatest public works manipulator of them all, liked to say, get that spade in the ground and it’s all over.

What happens if the steering committee gets to the end of its 18 to 24-month exploration and says “This is what we must have to keep Children’s performing at no less than its present level in patient care, research and teaching,” and Kaleida says, “But we can only afford a portion of that now, so we’ll begin with what we can afford and we’ll talk about the rest later”?

Is everything on hold until Kaleida delivers everything the steering committee wants? Is Kaleida enjoined from starting construction until it fulfills all the conditions precedent? Or does Kaleida just go ahead and do what it thinks it ought to do and has the right to do? If so, what real effect do the conditions precedent have? How would they then differ from mere suggestions?

What happens, say, if Kaleida decides–as John Friedlander suggested at last week’s press conference it already had–that tucking the pediatric pharmacy into an adult pharmacy was satisfactory and the pediatric physicians on the steering committee say that just won’t do at all? Whose will or judgment prevails?

What question will the steering committee ask? If the question is “What’s best for Children’s Hospital and its patients?” it might come up with one answer. If the question is “What’s best for Kaleida Health and UB and their constituent parts?” it might come up with another. Once it gets to the end of its quest, will the Kaleida board set about implementing that recommendation or will it set about attenuating that recommendation in terms of its current funding situation and policy needs? Will a medical need or a wallet determine whether or not Children’s actually moves and, if it does, what kind of hospital it becomes next?

We won’t know the answers to any of those questions until it’s over. It would be a lot easier if there were a fair measure of trust between the Children’s medical staff and Kaleida management, but there isn’t much trust there. I suspect the chances of the feasibility process being seen as anything more than a slight delay in the implementation of a plan Kaleida management already has in place are slim unless the steering committee includes some of the really articulate and informed opposition—not just members of Children’s staff who will work and play well with others, but people like Margaret Mcgillvery, Linda Brodsky, Brad Furhman, Joe Bernat, Michael Pizzuto–staff doctors who’ve been asking the tough questions all along.
 

CONSTITUENCIES

The Physicians Coalition looks at the proposed move in terms of their sense of Children’s Hospital’s present situation and future possibilities. John Friedlander and the Kaleida board look at the move in terms of a young, fiscally troubled medical organization trying to provide decent health care in a time of shrinking public and private financial support for health care. Michael Bernardino and the University at Buffalo are trying to create a medical system that is capable of engaging in a wide range of major medical research and provide quality medical education. Those desires and needs are each perfectly laudable. Is it likely or even possible that moving Children’s to High Street will answer all of them well?

There is a fourth constituency, one none of those three represents directly but each of them represents in part: the community as a whole. If the High Street medical corridor works as the dreamers dream, then everyone benefits, not just patients and physicians and Kaleida and UB, but also the speculators who are even now starting to scarf up parcels of land that are still underpriced, the construction companies who will build not only Children’s and its parking lot, but the new research building, the offices and labs for the technical companies that come along, all the people who will work in those offices, pay taxes, buy homes, shop in stores.

Hey, sometimes the lightning strikes. Look at route 128 around Boston, look at Austin, Silicon Valley, Seattle.

And sometimes it doesn’t. There’s Flint, Michigan, with a downtown to which no on ever came. They poured millions into a fine new convention center. Flint, Michigan, now has a convention center to which nobody comes either.
 

THE OATH THAT ISN’T

I was going to end this report with this:

You can’t tell the difference between fool and visionary until it’s too late to change direction. Perhaps the place to start any radical change is with the phrase every doctor utters on the day he or she is first permitted to go it alone: First, do no harm.

I wanted to be sure about the wording of that key phrase from the Hippocratic Oath, so I checked it on the web. Alas: I found the phrase nowhere. It’s not in any of the translations of the Greek Hippocratic Oath, and it isn’t in any of the half-dozen or so modern versions I came across.

There is no standard oath for doctors, you see. What they swear to depends where they’re doing the swearing. The AMA has no official oath, and not all doctors belong to the AMA anyway.

But here’s a curious thing: almost every doctor I know takes that phrase– “First, do no harm”–with utter seriousness. Even the flakly doctors pay it serious lip service. Whether or not they had to swear it the day they first got to put the grand initials after their name, most doctors take it as part of their creed anyway. On your way to making things better, you do everything in your power not to make things worse.

I don’t know what formal charge Kaleida Health will give to the steering committee, but maybe it wouldn’t be a bad idea if the formal document began with that phrase most people think doctors swore to already anyway and most doctors accept as if they had, First, do no harm.



Children's Hospital: Move It or Fix It, Part I: Interview with Kaleida Health CEO John Friedlander

Children's Hospital: Move It or Fix It, Part II: The Doctors Speak
 
 
 

Kaleida Health's Ellicott Street headquarters, with Roswell Park to the right, Buffalo General to the left and behind (on High Street) and the building on the corner of High and Ellicott that will come down to make room for the new Children's Hospital, should all of this come to pass.

copyright 2000 Bruce Jackson

 

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