(Artvoice 8 June 2000)
Move It or Fix It?
Part II: The Doctors Speak
By Bruce Jackson
(The second of two parts)
On April 1, 1998, Children’s Hospital of Buffalo joined with Millard Fillmore Hospital, Buffalo General Hospital, and DeGraff Memorial Hospital to form Kaleida Health, a new organization designed to ameliorate some of the financial problems all four institutions were then experiencing. It is the 39th largest medical system in the country, with nearly 2000 physicians on staff.
A UB medical official told me that last month, Kaleida reported a $4 million loss and its departments were just asked to cut their operating budgets by 4%. The UB Medical School may be cutting its class size by nearly 25%. It appears that out of all the component parts of Kaleida, Children’s was the most stable, the closest to being able to stay afloat on its own.
Many of the physicians at Children’s are now having second thoughts about the wisdom of the union. In part, that stems from a loss of autonomy and authority: previously, they could consider major policy issues entirely from the point of view of pediatrics, but in the much larger Kaleida system pediatricians are vastly outnumbered and outvoted. Kaleida is presently exploring ways of possibly rectifying that, at least in part.
More vexing is the strong advocacy by Kaleida president and CEO John Friedlander to move Children’s Hospital from its present Bryant Street campus and relocate it on a far smaller plot of land across Washington Street from Buffalo General Hospital. Such a move has strong support by University at Buffalo administrators. The new Children’s would be ten stories high, umbilically connected to Buffalo General by a bridge nine stories up. It would, for the first time, give the UB Medical School a geographically-focused campus.
The move would make Children’s part of the medical corridor being developed on High Street. It would be a block away from Roswell Park and near the new research labs planned for the area. The University of Buffalo has promised to provide up to $65 million for part of a new facility, but nothing at all for new construction if Children’s remains at its current location.
Feelings about the proposed move are running high, both in and out of the medical community. At a meeting at Westminister Presbyterian Church Tuesday night, about 150 people listened to Kaleida board chairman Tom Beecher and pediatrician Steve Lana discuss what has been going on. Beecher described the process that got Kaleida to this point, including the formation of an ad hoc committee to explore the proposed move. Lana said what was wrong with the whole idea from the physicians’ point of view. With only a few exceptions, the questions and comments from the audience indicated strong opposition to the move.
These are some of the questions being asked:
---Should Children’s Hospital stay on Bryant Street or should it move to High Street?
---Should millions of dollars be invested in rehabilitating and modernizing the current structure or should millions of dollars be invested in a brand-new building?
---Would the economic good resulting from moving Children’s to the East Side offset the harm the loss of Children’s would do to the West Side?
---Would it be possible to preserve the special culture of caring that makes Children’s one of the top-ranked pediatric hospitals in the nation if it were part of the Buffalo General–Roswell Park complex?
---Was the 1998 merger of Buffalo General, Millard Fillmore, and Children’s Hospital that created Kaleida Health a smart move in hard times or was it a fatal abandonment of autonomy?
---Would the present building or a new building structure better serve sick children?
Are children better served by a hospital that deals almost entirely with children or by a hospital complex that does everything?
---Is there a correct answer to any of those either-or questions, and all the others surrounding this critical issue?
These are tough questions, and none of them will be resolved by the report on the proposed move from the Kaleida Ad Hoc Committee expected later this month. Whatever the next step is—stay on Bryant Street and bring that facility into the 21st century, or move to High Street and find a way to let the special culture of Children’s propel that whole conglomerate—the architectural decision will be only the continuation of a long and difficult process that began when the city’s major medical institutions first got the idea that they might fare better joining together than going it alone.
You get different answers to those questions from Children’s Hospital physicians, Kaleida officials, UB administrators, Elmwood area residents. Who’s right? Can all be right? Is any “right” more right than any other? Are there valid competing interests? If so, which shall have predominance?
My favorite of Faulkner’s novels is Absalom! Absalom!, on the surface about an ambitious man named Thomas Sutpen but really about the way several people who never knew him or who knew him only slightly constructed a Thomas Sutpen that made perfect sense. The only problem is, the various Thomas Sutpens are incompatible with one another: the same person couldn’t have been and done all those things. At heart, Faulkner’s great novel is about the way we see, how what we are is as important as where we are in determining our field and scope of vision.
As far as I can tell, the three primary agents in this decision have three different points of view on the question of where Children’s shall be located and what its affiliations shall be: Kaleida Health (which is interested in business), the University at Buffalo (which is interested in education), and the physicians at Children’s (who are interested in delivering the best health care possible to children).
None of those interests is unique to any of those parties; all share them all. But they don’t share them to the same degree and they don’t define them in the same ways.
Public policy is easy when the question can be answered rationally. It’s easy to know what’s the right thing to do with the Peace Bridge, for example. Public policy is difficult when the question has several apparently rational answers. In Faulkner’s novel, we never do learn what the truth is; he leaves it open at the end. In public policy, you don’t have that out: at some point, for good or ill, a decision must be taken and real people must live with the real consequences of that decision.
Last week we printed part of a two-hour conversation I had about the proposed move with John Friedlander. This week we hear from three prominent members of the Children’s Hospital Physician’s Coalition:
- Linda Brodsky, pediatric ear, nose and throat surgeon,director of the Division of Pediatric Ear Nose and Throat at the Children’s Hospital, and professor of otolaryngology and pediatrics at UB;
- Bradley Fuhrman. director of the Pediatric ICU at Children’s and a professor of Pediatrics and Anesthesiology in the School of Medicine;
- and Steve Lana, a private pediatrician in general practice in Buffalo.
Before turning this space over to them I would note two things.
The first is that after talking with Mr. Friedlander and the three physicians, and attending several public meetings about the proposed move, I wondered if Kaleida wouldn’t do as well taking counsel from a competent cultural anthropologist as from all those business consultants they’ve hired. Business consultants look for ways to make something work most efficiently. Cultural anthropologists begin with the recognition that different cultures had different ways of behaving, perceiving, evaluating and expressing and none is necessarily any better than any other. They know that when cultures meet the problems are often as much grounded in the natures of the cultures themselves rather than the apparent topic of contention.
The second has to do with my unqualified admiration for the passion and dedication of the doctors. Nearly all the professionals I know are dedicated to their work or the people the serve, and most are dedicated to both, but I don’t know any who are as passionately dedicated to both the work and the clients as pediatricians. It’s not just that they’re better at expressing their feelings than other doctors. They really love those kids, they really care for their families. Cool professional reserve isn’t going to impress a neonate who can’t tell you where it’s hurting and how much, but attitude and tone sometimes do. These people have an attitude and tone that, after you hang around with them for a while, you can’t help but feel good about the human race.
Artvoice welcomes your comments on this issue. You can send letters to the office (500 Franklin Street, Buffalo, NY 14202) and email directly to me (firstname.lastname@example.org).
Both parts of this article are available online at www.brucejackson.net.
STAKES AND STAKEHOLDERS
In deciding whether or not to relocate the hospital, whether to renovate or not, they will be making decisions that will change the way medicine is practiced for children well into this century. It will be the last large investment in the Children’s Hospital for this half of the century. If it isn’t done in a way that has the children in the front of their minds, then they run the risk of destroying what’s already been built here, which is an excellent institution that provides excellent care for children.
This has been treated as a very local and private issue. It’s private in the sense that it’s a Kaleida issue. It’s private in the sense that it’s a neighborhood issue. It’s private in the sense that it’s a City of Buffalo issue. There are all these concerned parties that are called “stakeholders” and they’re trying to decide where to put Children’s Hospital, which actually is a critical issue for the community.
This is really a community issue, it’s an issue about what’s best for the children of Western New York.
What’s at stake is the future of Children’s Hospital and the future of children’s care in this region. Unfortunately, lately it’s been oversimplified into this sound bite of “location,” which is kind of absurd on the surface because who in their right mind would choose High Street as a replacement for Elmwood?
On the surface the issues have been, “We need to achieve economies through consolidation, we can save money, we need to provide all of the services to all of the community on one site, we need to promote this world-class medical center. The truth of it is, the only thing world-class in the system was the pediatric component. So the issue is, what will happen to the basic pediatric care in this area and who will be in a position to make those decisions.
Are there any advantages to the proposed move to High Street?
DR. FUHRMAN: Yes. But the advantages are primarily to stakeholders that have no interest in children.
From the point of view of the City of Buffalo, there’s the opportunity to convert a parking lot and a rough-hewn medical center into a medical corridor for the city, which they see as a way of focusing some of the activity of the city, perhaps a source of revenue.
For the university: this is a university that does not have a teaching hospital; instead, it defines its medical students and residents through a consortium of hospitals around the city. They’ve been scattered and dispersed and this is the opportunity to put them all on one site. It could grow programs that from the university’s point of view will look better to candidates, to applicants, perhaps to the nation if it’s all on one site.
For Kaleida, the High Street location offers several opportunities. One of them is that they compete with other health care provider organizations, and they want to be able to offer cradle-to-grave care under contract to third-party payers, they want to be able to do it in a way that it’s highly cost efficient so they can get their expenses down to minimums so they can be more competitive for their contracts. And there are advantages financially to having everything on one site. They’re not advantages to the child or the recipient of the services, they’re advantages to the provider, to the health care system.
There are stakeholders for whom the location of Children’s is critical in the Elmwood area, who would say it’s disadvantageous to move to High Street. From the point of view of the parents of the children in Children’s Hospital, the doctors who drive there at three in the morning, and various other people, location is an important issue, and it’s disadvantageous to move to a higher crime nonresidential area like the High Street location. So location is an important issue to various stakeholders.
Not to the three of us, I don’t think. To us, the big issue is where the best care can be provided for children, and that has to do with the circumstances surrounding the change.
There’s the idea that this is a community of stakeholders, but in reality there’s only one stakeholder, and that’s the patient. And the person through whom the patients express their needs, wants and desires–the physician. Those are the two who have the greatest stake in what is going to happen.
WHAT CHILDREN’S HOSPITAL IS
Children’s Hospital is not just a hospital. It is an entire range of services that’s delivered at a campus location. It has a fairly new in-patient tower. Outpatient services. Offices for the doctors. A research center. A rehabilitation center which makes us extremely competitive for certain types of grants. People come to Buffalo to give us grants for developmental pediatrics. They see that there’s one block between our rehab center and our inpatient and outpatient units and all the diagnostics. We have exceptional diagnostics, believe it or not, in Buffalo. They’re ready to give us money any time. The State calls up and they ask us, “What else do you want to do?”
It’s a conglomerate of services, all very well integrated now, all linked to one another. That’s what’s going on at Children’s Hospital. It’s really a medical center. The word “hospital” is a euphemism for that. The hospital itself is basically made up of inpatient services: ICU, emergency department, ORs, inpatient beds. Most hospitals don’t have outpatient departments, they don’t have rehab centers, they don’t have primary care clinics adjacent to the hospital, they certainly don’t have a research foundation that brings in $12 million in grants and foundation monies for such a small faculty.
We really work in the hospital. Our offices are in the hospital. If a kid comes to the emergency department, there’s somebody on site who can get that kid to the operating room immediately before he or she chokes to death. That kind of full-time faculty has evolved from when I got here 17 years ago. There are well over 110 doctors on Children’s staff, most of whom are listed in the Best Doctors in America book. You have to understand, this is not just 110 people who came together. These are some of the best people in the entire country.
Most of the people at Children’s don’t have another private practice someplace else. Their entire commitment is to the Children’s Hospital, as opposed to a cardiologist or pulmonologist at Buffalo General who may also have a private office someplace.
FACTS LOST AND FOUND
The merger took place April 1st, fittingly, 1998. Even before the merger there were long discussions about how governance structure would be set up and what might happen and what might not happen. We thought that we would be proactive and under the impetus of the chair of Pediatrics and the chair of Pediatric Surgery, the Pediatric Task Force was put together. It consisted of 90 physicians and administrators. We met the entire spring and summer of 1998, with the intent of presenting to Kaleida what we thought the vision was for promoting, enhancing and delivering pediatric care throughout the system. In other words, we thought that we had the franchise in pediatric care and now we would be given the opportunity to share—I’m not saying me, personally— but to share the benefit of the expertise of the training everywhere else. So we met the entire spring and entire summer. Administrators were involved. Physicians, family practitioners, everyone.
We generated a very well thought-out long report and presented it to the Kaleida board thinking we were helping, wanting to be team players, this is how we plan to contribute to the team, this is the expertise that we bring to the table. It was completely ignored, totally ignored. None of the things, even the things that required no investment of money were really acted on.
No location issues.
The rationale seemed to be, “We want to do this master facilities planning, we’re going to get some consultants from out of town and they’re really going to study this and analyze this and they’re going to come up with this great plan. But we’ll allow you doctors the opportunity to meet with the consultants.”
Hamilton, this nationally known consultant firm comes in and they start establishing regular meetings with members of the pediatric representative group. Again, we meet now in the 98-99 year almost on a weekly basis and part of that process involves electing six other cities with children’s hospitals of comparable size and scale so that teams, delegations can visit, go to these sites–the teams usually included an administrator, usually John Friedlander, the CEO or somebody close to him, and a handful of doctors. We’d meet with our counterparts in these places and basically pick their brains, find out what they did, how they’re doing things, how mergers affected them, what suggestions they might have, so on and so forth.
We collated all this information, we did surveys of newly-constructed children’s hospitals, what was the range in prices. We knew from that that we were in the neighborhood of $200 to $250 to build a first-rate new children’s hospital.
So we go on with what in retrospect was a charade, and Hamilton presents their report. And lo and behold, their report comes to the conclusions that were not supported by any of the facts that we discussed. And in a nutshell they say, that ‘we believe it will cost more to renovate the Children’s Hospital than it will to build a completely new hospital.’
At which point we’re outraged. ‘How did you come to that conclusion? Where’s the data? That’s not what we discussed.” They made a lot of other assumptions about the relative merits and demerits of the Bryant Street campus versus High Street campus.
And so it was then that for the first time we decided we needed to get some visibility in the public. Because up until then we had been working for well over a year behind the scenes. We were not making much of a stink, just playing ball, being part of the process.
That’s when Tom Beecher, who is chair of Kaleida, decided that he would appoint the Ad Hoc Committee. So now we’re in cycle number three of analysis. This Ad Hoc committee consists of some doctors, some of whom are pediatricians, and some community representatives. Their charge last August or July was to take what was done by Hamilton, by these consultants, build on it. Look into it in greater detail because the Hamilton report was unsatisfactory. There was a lot of hue and cry in the pediatric community, they didn’t really accept it, they didn’t think it was valid.
And so the Ad Hoc committee rolled up their sleeves and they engaged in a three-phase process. The first phase is of course that they have to be brought up to speed because a lot of them had no idea. We had spent two years addressing these issues. Some of them were just coming in fresh.
Were any of your people on the committee?
Two out of twelve or thirteen.
One of the first things the committee tried to do was take some sort of vow of silence. They were told that for reasons of comity and whatnot they really ought not to discuss things they were being told.
They actually had to sign nondisclosure statements. And they got these two big notebooks and they weren’t allowed to share them with anybody.
We said, “What are you doing? You can’t possibly be serious.” So they backed off a little bit on this.
A couple of interesting things happened in that first phase. Kaleida administrators decided to invest at least $30,000 or $40,000 producing a very slick colorful fold out brochure that looks like the conclusion to what the Ad Hoc Committee was charged to do. It basically says, ‘Just to bring everybody up to speed, this is what we’ve learned thus far.’ And they mail it to the entire Kaleida medical staff. Incredibly biased. At first glance, you look at it and you say, “Oh, gee, obviously High Street has all the advantages going for it.”
So while the Ad Hoc Committee is supposed to be fact finding, Kaleida blankets the medical community with this piece of propaganda that makes it clear it’s a no-brainer decision: You gotta go to High Street.
The Ad Hoc Committee disavows anything to do with it, and I doubt that they had the resources or the time. It’s clear that this came from the PR machine at Kaleida. They took a little bit of heat from that, but nevertheless, you can’t unring the bell. It’s out there.
Phase Two was “Now we’re going to get input.” So they start sending invitations to all of the stakeholders. But guess what? “We want input on our terms.” They sent out this two or three page letter about what you can or can’t do, and that you have to be an expert on something to comment on it.
We couldn’t speak on finances.
Because we’re not financial or marketing experts. Although many of us run very large departments and multimillion dollar budgets, and we all know medical practice.
But we played ball. We set out to gather as much data as we could and try to answer and address as many of the issues that they wanted us to address.
Part of that was a tour that the administration arranged for the new Ad Hoc members, because a lot of them had never set foot into Children’s Hospital. So they take them into the bowels, the sub-sub-subterranean. They show them the boiler system that is hopelessly antiquated, the worst possible spin you could put on it. The probably don’t go anywhere near the three-year-old state of the art ICU or the neurology rehab unit, the epilepsy center that maybe is one year old. There’s a lot of fantastic things in the hospital.
So they came out with this realization: “My goodness, we never knew that the hospital was in such a state of disrepair. Have you seen the boiler rooms? That place is going to fall apart. It’s incredible.”
This is an important point, this issue of the state of the building has been so misrepresented.
The reason I know that is because one of the former employees that they let go had access to all the hospital buildings and as far as the repair record, there was never ever a major breakdown at Children’s Hospital, unlike the Millard Gates or Buffalo General. The repair records were excellent, everything was kept up well. It’s certainly not the worst building in the system and if you go any hospital bowels you’re going to find a lot of bad things. You have to put this all in perspective. It’s not that they had a comparison here. They were just shown the very worst of the worst and this is the tenor of the entire process.
I served on many Kaleida task forces, and they’re all the same. They bring in consultants, you work on it, you write everything down, and you come back again and there’s no relationship to what the work was done and to what was presented to you—and they present as your work, and they say, “The doctors bought into this.” And this is what’s been most disturbing, is this process.
“BY MERGING WE ACTUALLY GOT SMALLER”
Did the staff at Children’s have a voice in the merger?
Not really. It was done by the board. And the board did it with the best of intentions, I believe.
Children’s has been in precarious financial shape for many many years, and they made a choice between having to declare insolvency, which is what we should have done, and joining in a merger. If we had declared financial insolvency they would have sent in bean counters to find out why. One of the things that would have been obvious is that the cost of delivering adequate care is much greater than the compensation in Western New York. This is a part of the world where insurance rates are among the lowest in the country. They’re kept that way to favor industry and the result is that we’re building industry on the backs of children, in a way that you can’t do with child labor laws. But they are taking advantage of very low insurance rates to build industry, the state is saving money hand over fist by paying almost nothing for medicaid patients. The third-party payers who have absorbed medicaid have realized that they’re not going to make the windfall profits that they’d expected to, and they therefore can’t afford to provide as much money for care as they expected to, so they’ve all cut their rates.
We have this problem where the finances are precarious because the pricing is too low, and had we declared insolvency there’s at least an even chance that someone would have looked at this and said the reimbursement system is wrong.
In any event, they went into this merger thinking that it was the financially wise thing to do without thinking very much of what the children’s stake in all this was.
To be fair, there were some people who spoke up. There are two very excellent letters by Dr. Greenfield, who’s head of Urology, who predicted all of this happening.
There were inducements to come into the merger. If we joined the merger we would now be able to gain the reimbursement rates for residents. You know, they pay $150,000 support for a resident when they work at adult hospitals because it’s through the Medicare. But at pediatric hospitals they get almost nothing per resident from the Medicaid-driven system. That’s changed. New laws have come out and now it’s more favorable for Children’s hospitals. Those laws were being considered at the time that this merger was going through.
They told us we’d get $8 million like that. And everybody, especially our academic leadership, really drooled over that money. Other inducements were that all the salaries in the system would be brought to par. The nursing levels would be the same. The doctor’s salaries would be the same.
They never once talked about moving the hospital, they never once talked about any of those kind of things.
And they also told us some other things that were very misrepresentative. For example, they told us that in a full-asset merger you must have a single medical staff, which meant that the governance of Children’s, which we were all very concerned about, would be lost.
It’s true that you must have a merged medical staff, but that does not mean that you can’t have a sub-corporation, you can’t have sub-boards, it doesn’t mean that you can’t have separate medical staff and privileging. There’s all these different ways to get around it. We consulted with other places to find out how it’s been done. Because it’s been done other places.
So we were told things and, you know what, we were taking care of patients, and you’re so busy running, doing what you think you’re supposed to be doing. You don’t pay attention, you trust.
And that’s why we’re not trusting so much now.
On the surface, there were some theoretical, ideologically sound reasons. We had been told time and time again that our health care system expends too much, our community is overbedded, we have too many resources for the population, that it would make sense to achieve economies of scale, all the buzzwords came out. It was the height of merger-mania: you get bigger, you achieve leverage with the payers, you are then able to negotiated these global capitation contracts and we will now no longer be pushed around by IHA and Community Blue because we’re going to be part of this big powerful organization and they’ll have to deal with us.
But by merging, we actually got smaller. We didn’t get bigger, we got smaller. Because instead of being masters of our own fate now we are basically at the whim of the majority, which is not pediatric.
And I think that as pediatricians probably a lot of us were naive. A lot of us thought, “Well, gee, I can see that by being part of this system, here we’ve got Millard Fillmore and Buffalo General and both of them have parallel services, none of those services are probably working at full capacity, that’ll make sense. They’ll merge and then they’ll have one full capacity, but they wouldn’t do that to Children’s ’cause there’s only one Children’s Hospital. What’s to consolidate, what’s to merge, where are the economies going to come? You can’t buy in bulk for adults and children.”
So we were incredibly naive thinking that we were going to be having the franchise in children’s care and it would be the adults who would merge because logically that’s where the excess capacity was. But that’s not the way it’s happened.
So far we’ve talked mostly about process and I think what you’re getting into now is what’s wrong with what we’ve got. Part of it is just going to reflect on the merger and another part has to do with the issue of renovating or relocating Children’s.
Are the two issues separable?
They are separable. So let me take purchasing and just try to give... I hope I can do this. This is not easy.
Purchasing–we belonged, we used to belong to a mass purchasing program that is subscribed to by multiple children’s hospitals. So there were fields of items that we could choose among that we could purchase at a discount rate. Kaleida, before the merger was complete, had already joined a purchasing plan, a mass purchasing under which the whole system got a big discount. Children’s Hospital now purchases through this purchasing system.
It turns out that the items that mass purchasing program provides are not always suitable for children. To get things that are suitable for children, we therefore had to go outside and buy them without a discount. They didn’t understand that there would be differences between what we needed and what an adult hospital needed, so that we ended up with a lot of things that suddenly appeared on our shelves, and what we used to work with suddenly vanished and all at once we couldn’t accomplish our patient care chores.
I was in the middle of resuscitations discovering that things didn’t fit together to give adrenalin. So it was a very risky thing.
This is a process that I’m going to refer to as homogenization. You’ll find that word now in a lot of the Kaleida literature. I have to tell you that it’s Newspeak. I made it up. It is Newspeak but it’s descriptive. What it means is, instead of having a carpenter shop where you put some things together with bolts and some things with screws and some things with nails, all you buy are nails and the only tool you need is a hammer. It’s a lot cheaper. So you do that in purchasing. But in purchasing it means that the hospital that has to buy all of its things outside of its system gets cost-accounted for a tremendous cost per. It means that they get nails to put together pieces of paper, that things just aren’t appropriate for them.
Now, Kaleida did recognize this when it was pointed out to them, and the head of purchasing is working very aggressively to solve this. They set up a separate value analysis team for Children’s Hospital under which we now deal with all the selection of new items for Children’s, we’re going back through the things that were loaded on us last year and we’re getting appropriate things. Sooner or later we will get this purchasing company to give us those things under their contract at a lower rate and some of this we will fix.
But every time we discover something like this where we’ve been homogenized, we run a couple of years of risk and deficit. Purchasing is just example of it.
There is a force generated when you have two hospitals working together that tends to make them share, tends to make them do things in similar ways because it saves money. This is the money that Kaleida is going to save by locating us next to High Street. This process, the forces that are involved, is stronger the closer the two institutions are. Just like the force of gravity, the forces of electromagnetism, the force of charge.
The principle is pretty simple. If we go into a merger of sorts with Boston Children’s for doing something, we won’t homogenize very much because we buy things locally, and that distance protects us. Distance from Kaleida, distance from Buffalo General protects us from becoming an adult hospital for children. The closer you put us the easier it is for us to share certain things.
Just as a couple of examples. If you put us close enough together, you can have one administrative team. We don’t have to have our own administrators at Children’s Hospital, after all, the office is just across a bridge. So you have one administrative team. That means that all policy will be shared, and they’re already doing it to some degree. But the more they micromanage, the more the sharing of policy means that they run our outpatient department like their outpatient department, our operating room like their operating room. It becomes homogeneous. You can share facilities, and who wouldn’t?
I mean, if you could build one radiology suite instead of two, you save a bundle. We’re not talking about sharing food preparation. We’re talking about sharing clinical departments. Well, then, if you’re going to have one radiology department, just hire one staff. Don’t hire as many as you used to have. Hire two-thirds as many because you don’t need as many for cross-coverage. So if a little kid, a two-year-old, comes in with a broken arm, let an adult radiology tech take care of him.
No. A two-year-old doesn’t know how to protect his arm. You have to know little things, like how to handle children to get cooperation, how to protect the arm for them so they don’t get hurt while you’re trying to get the x-ray. Adult-oriented people will not know that.
So the closer you get the more of these things you share, the more homogeneous services become, the more we become a hospital for little teeny tiny adults, and we will cease to be as a children’s hospital.
You hear a lot about losing the emblem of Children’s or losing the insignia or losing our identity as Children’s Hospital. That is NOT the risk. It’s losing our ability to give child-centered care, to give a unique kind of care to children.
“CHILDREN ARE NOT SMALL ADULTS”
What is the difference in the kind of care you provide for adults and for children? What difference does it make between being a big hospital that does everybody and just doing children?
The technology is different. Children’s has the fastest CT scanner in the world. That’s because when a child goes to the CT scan after a head injury we don’t want to have to sedate them, we don’t want to spend a long time ventilating them with a hand-bag and a machine, so we have a special kind of scanner for that. We have another CT scanner that’s very specific for fine structure, and that CT scanner we’re probably going to lose.
That’s already cut out.
That’s the one that you use for certain kinds of procedures related to anatomy of the ear. So that kind of technology, technology that involves little things rather than big things, which is a big difference, that sort of thing, if it gets homogenized, it makes us just have the wrong stuff.
Then there are issues of whether or note the pharmacy will do a good job with pediatric dosing. For adults, you get a pill three times a day if you’re in the hospital. My patients get a certain number of micrograms per kilogram per minute. Our pharmacy is equipped not to make drug errors. They gave us a new policy, a new format, built for relating to the pharmacy so that we can do the same thing Kaleida-wide and in space of two weeks we had as many medication errors in the intensive care unit as we typically have in one year.
I want to address that point, because I led the national thirteen-hospital consortium medical errors study and the intensive care unit was the focus of our study. We began with four weeks of surveys of drug prescriptions and this issue of medication was right on the front page from the Institute of Medicine. Kaleida, what they’re planning is to have no pediatric pharmacy, when really the state of the art everywhere is to go to on-site satellites within the intensive care unit. And that in and of itself is the most dangerous thing that I can think of because it’s really truly a completely different way of thinking of patient care.
Besides that, don’t forget, these little kids can’t, don’t take care of themselves. They’re helpless. If you don’t get your pill or you get two pills, you say, “This is not the pill I’m supposed to be taking.” But a kid doesn’t know that it’s being injected into the wrong IV or something like that.
You’ve got a whole family to take care of. There’s not just a patient. There’s a patient and its family. And often its extended family. There’s a lot of different relationships–social services and
whatnot. This pharmacy issue is to me so worrisome. It’s something about to, I think to explode, especially as we’re embarking on the next phase.
There are a lot of other things. Children have different diseases than adults. So we need different equipment to deal with their problems. Our heart cath lab is nothing like an adult heart cath lab because our patients have congenital heart disease, not coronary artery disease. Children simply are very very different and they therefore need very very different patient contacts, kinds of therapies, amounts of supervision, et cetera.
It is not just a matter of size. I mean, who has hyaline membrane disease an adult hospital? When do adults get mid-gut volvulus?
The physiologies are different. The disease processes are different. The disease of adults is a disease of wear and tear and age and self-abuse. The disease of a child is the disease of inborn errors or developmentally skewed process and infection. So the whole paradigm is different, the whole approach is different. So when we say children are not small adults, it’s because the diseases they get are different, because the approach is different, because the way they’re treated is different.
The diseases and the circumstances are so different that there are separate specialties for children and adults. There are ENT doctors who do pediatric ENT. They deal with pediatric issues, with children’s issues. There are brain surgeons who deal with the kinds of problems that children have.
It’s not just a matter of smaller brains?
It’s not just smaller brains, it’s different problems. So the people who work at Children’s, the physicians who work at Children’s, the dentists who work at Children’s, even the nurses who work at Children’s have different training and different subspecialties.
I’m a pediatric intensivist. I would no sooner take care of somebody with a heart attack than run for president.
Kaleida doesn’t know what they need and what they risk in making changes so that the hospital can’t effectively delivery specialized care to children is that doctors won’t want to come here if they can’t practice their craft, and then the care won’t be available. Seventy percent of our physicians, of the full-time faculty, come from outside of western New York. So they will not be here if everything is homogenized and we’re not able to give the special care that children need.
The part of the hospital that takes care of critical illness, life-threatening illness involves the emergency department, which is on the first floor; on the second floor radiology and heart cath and CP scan, MRI, operating rooms, and the intensive care unit. And then on the 3rd floor is the newborn intensive care unit, intensive care nursery, and labor and delivery.
These things fit together like a jig-saw puzzle. They grew over time. They got arranged the way they are because they evolved to be that way.
Basically a patient comes into the emergency department and gets stabilized in an area that’s separate from the other kids. There aren’t normal kids watching him bleed all over the floor because it’s a separate area. If a healthy kid comes into the emergency department he’s not next to a rape victim or somebody who’s just been shot with a gun. He isn’t sitting in the same lobby with a bunch of motorcyclists. We have an emergency department that’s just for children.
One of the problems with gunshot wounds with stabbings is the friends they keep. And we have let that stay at Erie County Medical Center and we do head trauma and things that don’t involve culprits because we don’t want the culprits visiting.
So we’ve got a nice emergency room on the first floor that’s capable of stabilizing patients. All the doctors, all the services that work at Children’s Hospital that might be called upon to work in the emergency department are geographically present. Our neurosurgeons aren’t two miles away as at Buffalo General and they’ll come back when they can get their car out of storage. They’re on the premises, so if a child is coming in by ambulance he is met by trauma surgery, neurosurgery, emergency department, pediatric intensive care, sometimes anesthesiology.
Once stabilized they go up to the second floor where we have this large horizontal adjacency.
There is an elevator dedicated to that. They can go up as high as obstetrics, that’s it. You need a card to get onto it. And it goes up to the second floor. If the patient needs a rapid CT scanner, we’ve got the fastest one in the world. If he needs to go to the operating room, it’s right there. Literally, there is a radius of about 50 yards that includes all the high-acuity services that that patient will need.
They go back and forth between these various components on the second floor something like 1600 times a year, round trips with critically ill patients who either go from the ICU while they’re on a ventilator to be a CT scan or an MRI, or they go to the cath lab for somebody who has had a crisis of some kind. Or we go into the operating room for a problem there or the surgeon’s run into the ICU for a problem.
It’s all right there. This is such an important adjacency that when I came here and they needed a new intensive care unit I realized that it had to be more than twice as big as the existing one in 1991. They considered just renovating and making it small and that wasn’t acceptable to anybody. They considered putting it up on the 6th floor and that wasn’t acceptable to anybody because it disrupted this horizontal adjacency. So what they did was they built the Alfiero Family Pediatric ICU on stilts. It’s a one-story building on stilts at the level of the second floor to maintain these adjacencies.
So that’s a 72,000 square foot adjacency using the Kaleida numbers for a new hospital on High Street. And above that there’s the intensive care nursery, one floor up from the ICU. We share patients back and forth with them because we have some things that we offer their patients that they can’t offer up in the intensive care nursery. They are horizontally related to labor and delivery, they’re one floor up from the operating room, they’re one floor from all the radiology facilities, from the heart cath lab, so even though they’re not on the same floor, they’re one stop on the elevator.
If you look at the diagram High Street, the building needs to be 10 stories tall because they wanted to put labor and delivery in Buffalo General on the same floor nine floors up as the intensive care nursery. So that would lead across a bridge.
Why do you have to have the hospital on that particular parcel of land? Because if you don’t, then it destroys the whole reason for building a new hospital. If you can’t have a connecting bridge between labor, delivery and obstetrics and the intensive care nursery, then you may as well be on Bryant Street as on High Street because you no longer have that adjacency.
That’s a 1.3 acre site. I think the correct number for our present site is 7.9 acres. They want to compress it into something very little. As soon as we presented this to the Ad Hoc Committee they did take pause, they did realize that their necks were pretty far out, here they’re going to be the stewards of the children of western New York and make the right decision and be remembered for it by name and all of a sudden they realize that this diagram they have isn’t quite right.
We’re not stupid. I’m not an architect, I’m not an economist or financier or a health care wizard. But we have been treated as though nobody is looking. We’ve been treated as though nobody is going to provide oversight to this, no one is going to care what they do and they’ve forgotten that when they acquired Children’s Hospital they didn’t pick up another franchise. They didn’t pick up a way of marketing cradle to grave. They picked up a stewardship for a unique western New York program that offers something you can’t have in western New York without Children’s Hospital of Buffalo. There isn’t another facility like that. The next closest one–there’s one in Cleveland, there’s one in Pittsburgh, there’s one in Boston, there’s one in Long Island.
The Rehab Center is not owned by Kaleida. The Rehab Center looks at 30,000 patients a year, has at least 50 or 60 doctors who interact there with their patients, and a number of therapists–well over 70 or 80—who go back and forth between the hospital on a continual basis. They walk one block. There are patients who are multiply-handicapped, all of whom are in wheelchairs, are on oxygen, or wear braces: they go back and forth between the hospital. Because the hospital has all the fancy diagnostics, we have the outpatient clinics.
Imagine if the Rehab Center is on Bryant and those 30,000 patient visits a year have to go to High Street. Those are our most difficult patients, that’s one of the big reasons we exist.
We take the critically ill–I see a lot of kids with tremendous long-term problems, complicated care, nobody else wants to take care of. Because they are so complex: they might have swallowing and drooling and aspiration problems where they choke on their own secretions. They can have horrible faces that have to be recreated, they have genetic diseases that metabolically they look a mess. You name it. And they are a tremendous burden on the family. That one case alone would be tragic.
The plan is for the High Street outpatient building to be separately administered and not child-specific, a university building, so you go back and forth between the hospital every time you need an x-ray. My office hours, if I see 30 patients, 15 of them are going to have an x-ray, a lab test, and now all that is somewhere in the hospital. You can bring them back to your office for another visit, as might occur out in the community, but you don’t. You want them to come one time, you spend the time with them, you get everything taken care of, and then you discuss where you’re going to go and what kind of plan you’re going to do. This is will be very hard: you go out and go to two different buildings administered by two different sets of people? That’s impossible.
And doctors will have to go back and forth. If I have a kid that is upstairs and is not breathing and I’m in my office at Children’s I can run three flights or five flights and I can be there in a minute, or less if I have to. But if I’m in my office across the street and I have to run and it’s five to seven minutes–and you’ve seen me run for an airway–because you can lose a kid like that! And unfortunately, some airways there’s nobody but an ENT who can get into, some airways, because it’s a surgical problem.
So these proximities are crucial.
We have a women’s and children’s research foundation center and that’s right down the block. Most of the research that we do at Children’s is through the Center. The statistical analysis, the data, the inpatient clinical research center, all of these things. We also have a school, a school and a laboratory for indigent children with developmental speech and language. At ENT, we rely on them all day, every day. There is not a day that goes by that they don’t seen 20 or 30 of our kids. Where are they going be? They’ll have to go to an outside vendor like Buffalo Speech and Hearing, which is a very fine vendor, but they are not child-specific.
So this is the incredible irony and the incredible internal inconsistency, was that on the surface it would appear that you’re trying to put all of your services in one campus, but what you’re really doing is dismantling a fully-integrated well-functioning comprehensive campus for the appearance–
Because “the ventilator ducts are too small.”
All they’re building is an intake/inpatient tower for 270,000 square feet, compared to what we have, 600,000 square feet, and it’s still too small for us.
And they’ve given a price tag for it–
Not only is it impossible, but it’s a price tag without knowing true square footage, what the thing is going to look like–what they did is they said, “270,000 square feet, so many dollars per square foot. This is a new hospital.” They don’t even know how many blocks of property they have to own to relocate until they do a flushed out plan.
SAVED US FROM WHAT?
I heard someone say of Children’s Hospital, “Those people were in dire financial straits when we came along. We saved them. They could not possibly exist without Kaleida right now. What complaint do they have if we want to move them over there and give them a beautiful new building. Would they be happy if we said, ‘Okay, we’ll give you whatever building you want?’” Could they?
Why would we NOT want a nice new children’s hospital to work in? It’s illogical to just snap at the hook for this. The reason is, that you can see underneath the bait that there’s a hook there. That it is not in our best interests to do this, we do not believe.
Just show me the plan.
Develop a plan that we can look it. If they develop the plan and it’s $400 million, then they may have to back away from it. If they develop it and it’s a very acceptable-looking plan and it’s $150 million , that’s a very different sort of thing.
Most of the mergers that occurred during this merger madness between 1996 and 1999 have unraveled. Because the ideas of larger really have not panned out. In fact, it’s been negative in almost every instance. There hasn’t been a successful merger, and certainly not one with a children’s hospital. The Detroit children’s hospital merger is being unraveled after ten years; they destroyed a very good institution there.
So when you say, “They were in dire straits and we saved them.” Saved us for what? I don’t feel saved. Saved us from what? Bankruptcy.
I think they should have declared bankruptcy, let someone come in and look at the books, figure out why we were having so much difficulty meeting the cost of taking care of patients. Forty-five percent of our patients are Medicaid.
In retrospect we have to question the advisability of aligning in one system. When you have the only game in town, when you have the only pediatric service in town, why not be the Switzerland and serve everyone? Clearly what we risk now is a situation where the Catholic system develops competing services that make money at the expense of drawing patients from the Kaleida system. Children’s Hospital in the final and ultimate solution, should be back out of Kaleida and should work in some sort of arrangement so that they can be the provider of the pediatric care to the entire region, not just to the Kaleida Health system, but to the entire region.
This region does not have a population base big enough barely to support one children’s hospital, and if were going to start over we probably wouldn’t have what we have, but the point is, we have it, let’s fight to keep it.
What would be for you a decent outcome of the current situation?
I think they need to have a bona fide study, they need to gather facts objectively and come up with a true plan, an apples to apples comparison can be made, they should make it, and then we should make an intelligent decision.
Different stakeholders have different perspectives on this. The restaurant next to Children’s sees things from the point of view of being a restaurant next to Children’s. A restaurant on High Street, somebody who wants to set up a restaurant would see that differently. Kaleida has their own way of viewing all this. But from the point of view of the children of western New York, this is the one chance they’re going to get in the next 50 years to have a reasoned decision with a well-studied plan. And it’s the responsibility of Kaleida to provide this. Because they’re the stewards, they were given this–terrible word–franchise.
I think that the facts are all there. I think that there’s been enough study. The study has been done and I think that they have gathered an incredible amount–in fact, I think there’s too much–of information. The issue is knowing what we have and is it really possible to enhance it in another location for a price that we can afford?
And if anybody’s going to tell me “Yes,” I think they’re taking me for a fool. I don’t think that there is anything but to invest what we have in a step-wise plan, one piece at a time, so that when we’re done with the new newborn intensive care unit, we’ll look around and we’ll say, “What do we need to do next to piggyback onto that?”
The new IN is now on hold. All the money is there but it’s not being done.
This is enough. They’ve fooled around enough. The public really has spoken. You had to be at the Flickinger luncheon or the United Way luncheon, or you have to be in the offices where we have thousands of signatures on petitions, doctors and patients alike, who are the people who really are—I mean let’s get real. Hospitals exist because of doctors and for doctors to bring in their patients. And the good medical systems understand that. But our medical system has a leader who really does not believe in the worth of the doctor and therefore the patient.
Patients don’t come to Kaleida Children’s Hospital. They come to see Dr. Brodsky or Dr. Lana or Dr. Soandso, and if Dr. Brodsky or Dr. Lana or Dr. Soandso leaves and goes somewhere else....guess what? The patients will go there.
So I think that this whole issue of doing more and more studies is—enough!
Children’s Hospital is a nationally and internationally known institution. It’s ranked 17th in the country. The rest of what Kaleida has to offer is nowhere near that league. Why would the company take its jewel and disrupt it? When you have something that’s worked—the Children’s Hospital Foundation alone has raised more than 3 or 4 times than all the other hospital foundations put together—why do you disrupt something like that? Don’t fix what isn’t broke.
Don’t break what’s not broke. You don’t break what’s not broke! If it’s not broken, so don’t break it.
Seventeen years I’ve been there and I’ve seen it go from nothing to really something. Every time there was a big crisis in finances, somehow we got through it, and we built again and again. Find us better contracts. Find us the least equipment cost.
I teamed up with a laser company. We now have the best lasers, every laser but one. For almost nothing because I teamed up with a laser company. And I got them, as part of my contract to do work for them they had to give us lasers at cost, and below cost, and extra lasers, and the finest lasers. Help us do this. That’s what the administration is there for, they’re there to help us, not to impede us. And our waste of time for the past two years has been a killer. It’s really been a killer.
Part I: Interview with Kaleida President and CEO John Friedlander
Part III: Children's Hospital: What Now?
copyright 2000 Bruce Jackson