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1 Code Blue Health Science Edition Four Richard E. McDermott, Ph.D. Traemus Books 2481 West 1425 South Syracuse, Utah 84075 Phone (801) 525 -9643 Fax (801) 773 -7669 www.traemu s-books.com [email protected] 2 CODE BLUE — Health Science, Fourth Edition. Copyright 2013 © by Traemus Books. All rights reserved. Printed in the United States of America. No part of this book may be used or reproduced without written permission except fo r brief quotations embodied in critical articles or reviews. For questions or inquiries contact : Traemus Books, 2481 W 1425 South, Syracuse, UT 84075, phone (80 1) 525 -9643, fax (801) 773 -7669, email [email protected]. This novel is a work of fiction. Any reference to historical events; to real people, living or dead; or to real locales is intended only to give the fiction a sense of reality and authenticity. Names, characters, places and incidents are either products of the author’s imagination or are used fictionally, and their likeness, if any, to real -life counterparts is coincidental. To order copies, see Order Information on last page. Instructors: To order instructors materials including test bank, answers to student questions, and PowerPoint lectur e slides, e -mail author at carol @traemus - books.com. Include name, title, institution, department, mailing address, e -mail address, phone, and the course for which materials will be used. 3 Table of Contents Major Characters ................................ ................................ .................... 10 Acknowledgments ................................ ................................ ................... 12 Preface ................................ ................................ ................................ ...... 13 Chapter 1 — Trip to McCall ................................ ................................ .... 18 Changes in managed care Discussion One — Communication ................................ ........................ 22 Discussion Questions ................................ ................................ ............ 22 Writing Exercise ................................ ................................ ................... 23 Chapter 2 — The Board ................................ ................................ ........... 24 Disc ussion One — Power and Politics ................................ ................... 27 Discussion Questions ................................ ................................ ............ 27 Chapter 3 — A Ch ange of Seasons ................................ .......................... 28 The importance of teams Quality assurance HIPAA and EMTALA Risk management A shabby termination — treating employees with respect The new healthcare environment Discus sion One — Employability Skills ................................ ................ 39 Discussion Two — Terminology ................................ ............................ 42 Discussion Questions ................................ ................................ ............ 44 Writing Exercise ................................ ................................ ................... 45 Role -playing Assignment ................................ ................................ ...... 46 Chapter 4 — Resolve and Regret ................................ ............................ 47 Should hospitals be run like businesses? Confidentiali ty in employee communication Operations and the role of the board of trustees Operational problems within the hospital Disc ussion One — Assuming the Reins ................................ ................. 54 Discussion Two — Teamwork ................................ ............................... 55 Discussion Questions ................................ ................................ ............ 59 4 Chap ter 5 — Amy ................................ ................................ ..................... 63 How hospitals dehumanize patients Discussion One — Patients’ Bill of Rights ................................ ............. 65 Discussion Two — Healthcare Ethics ................................ .................... 66 Discussion Questions ................................ ................................ ............ 69 Guidelines for Answering Bioethical Q uestions ................................ ... 71 Bioethical Case St udies ................................ ................................ ......... 74 Chapter 6— Quality Assurance — The Plan ................................ .......... 79 Malpractice Peer review Total quality management (TQM) More on EMTALA and patient dumping Purpose of morbidity and mortality commit tee The 100k Lives Campaign The legal liability of the board for quality Purpose of the credentials committee Applying for medical staff membership Purpose of the infections committee Purpose of the quality assurance committee Discussion questions. ................................ ................................ ........... 84 Chapter 7 — Implementing Quality Assurance ................................ ..... 85 Strengthening the process of granting medical Staff privileges Economic ramifications of denying medical staff Membership Discussion One — Risk Management ................................ .................... 88 Discu ssion Two — Hospital Infections ................................ .................. 89 Discussion Three — Applying Principles of Body Mechanics and Ergonomics ................................ ..................... 92 Discussion Questions ................................ ................................ ............ 93 Chapter 8 — Cultural Diversity ................................ .............................. 94 Culture Ethnicity Race Cultural blindness Discussion One — Discrimination ................................ ......................... 99 Racial discrimination Sexual discrimination Age discrimination Disability Sexua l preference 5 Discussion Questions ................................ ................................ .......... 103 Chapter 9 — High Noon ................................ ................................ ......... 104 Financial problems caused by managed care Insolvency and bankruptcy Business plans Discussion O ne — Consequences of Bankruptcy ................................ . 109 Discussion Questions ................................ ................................ .......... 109 Chapter 10 — Never Give Up ................................ ................................ 113 Developing personal character Non -responsive service departments Discussion One — Overcoming Discouragement ................................ 114 Discussion Two — Deciding Priorities ................................ ................ 114 Discussion Three — Participative Management ................................ ... 115 Di scussion Questions ................................ ................................ .......... 115 Writing Exercise ................................ ................................ ................. 115 Chapter 11 — A Dynasty Falls ................................ .............................. 117 Chapter 12 — Why Are Costs So High? ................................ ............... 120 Health economics — the study of scarce resources Discussion One — The Impact of High Healthcare Cost s on the Economy ................................ ................................ .... 122 Chapter 13 — A Lesson in Medical Economics ................................ ... 123 Dramatic increases in healthcare costs The absence of price competition Characteristics necessary for a free market The absence of price elasticity Exc ess capacity Disc ussion One — Unreimbursed Care ................................ ................ 130 Discussion Questions ................................ ................................ .......... 131 Chapter 14 — Gaming the System ................................ ........................ 132 The impact of cost reimbursement on healthcare costs Why nonprofit organizations have to earn a profit Discus sio n Questions ................................ ................................ .......... 134 Chapter 15 — Adverse Incentives ................................ ......................... 135 Attempts to control costs through regulation Blue Cross and cost control The evolution of hospitals from poor houses Prospective payment and incentives for cost control Cost reimbursement and incentives for cost control 6 Health maintenance organizations and cost control Discussion One — Systems ................................ ................................ .. 139 Definition of a system Generic systems Advantages of sys tems thinking Discussion Two — The American healthcare delivery system ............ 141 Inputs Throughputs Education and treatment resources Finance mechanisms Management and control mechanisms Information and feedback system s Output The healthcare delivery system is like a mobile The Patient Protection and Affordable Care Act ............................... 148 Pay for Performance ................................ ................................ .......... 154 Discussion Quest ions ................................ ................................ ......... 155 Chapter 16 — Is There a Solution? ................................ ....................... 157 Captive health plans Capitation payment Indemnity insurance plans More on health maintenance organizations Diagnostic related groups ( DRG) Dis cussion One — Ha ve We Got What We Asked for? ....................... 165 Discussion Two — Listening Skills for t he Healthcare Professional ... 165 Discussion Questions ................................ ................................ .......... 166 Chapter 17 — The Robbery ................................ ................................ ... 168 Compassion versus profitability Discussion Questions ................................ ................................ .......... 173 Chapter 18 — The Hospital Bazaar ................................ ...................... 174 Discussion One — Why Financial Ratios Don’t A lways W ork in the Healthcare Industry ................................ ..................... 179 Discussion Questions ................................ ................................ .......... 179 Chapter 19 — The Model ................................ ................................ ....... 181 What makes for a successful life? Discussion Questions ................................ ................................ .......... 185 Chapter 2 0— Rachel ................................ ................................ .............. 186 7 Chapter 21 — The Plan Takes Shape ................................ ................... 189 Hospital compensation Performance evaluation Discussion One — Wes’ Approach to Saving the Hospital .................. 191 Discussion Questions ................................ ................................ .......... 191 Chapter 22 — Inadequa tely Trained ................................ .................... 192 Trouble with the Department of Justice Disc ussion One — Reducing Mistakes ................................ ................. 199 Discussion Two — Legal R esponsibilities of Healthcare Workers ................................ ................................ .......... 200 Unintentional torts Negligence Intentio nal torts Assault , battery, false imprisonment, abuse, defamation, invasion of privacy Legal regulations of healthcare practice Insuring competence Other legal issues Risk management Discussi on Three — Cost versus Quality ................................ ............. 208 Discussion Four — Everyday Ethical Issues ................................ ........ 209 Discussi on Questions ................................ ................................ .......... 209 Chapter 23 — Ramer ................................ ................................ .............. 211 Discussion One — Fraud ................................ ................................ ...... 215 Discussion Questions ................................ ................................ .......... 215 Chapter 24 — Waste and Fraud ................................ ............................ 216 Materials managem ent Common fraud practices Other controls to healthcare care costs Pre -certification Gatekeeper physicians Physician panels Discussio n Questions ................................ ................................ .......... 219 Chapter 25 — The Revenue Equat ion ................................ .................. 221 Out -migration Bigger -is-better Syndrome Reasons for decreasing inpatient revenues Other sources of revenues Physician skimming Discussion One — Cutting Losses ................................ ....................... 224 Discussion Questions ................................ ................................ .......... 224 8 Chapter 26 — The FAA Report ................................ ............................ 225 Discussion Questions ................................ ................................ .......... 227 Chapter 27 — An Audit of the Pharmacy ................................ ............ 228 Discussion Question ................................ ................................ ............ 231 Chapter 28 — Facility Problems ................................ ........................... 232 Hospital fire and safety codes Discuss ion One — Safety in the Hospital ................................ ............. 235 Oc cupational Safety and Health Administration (OSHA) Center for Disease Control (CDC) Clinical Laboratory Improvement Amendments (CLIA) Discussio n Two — The Hospital Fire Plan ................................ .......... 236 Discussion Three — The Hosp ital Disaste r Plan ................................ .. 236 Discussion Questions ................................ ................................ .......... 238 Chapter 29 — Ramer’s Reversal ................................ ........................... 240 Chapter 30 — Paradigm Software ................................ ........................ 242 Chapter 31 — First Management Reports ................................ ........... 246 Discussion Questions ................................ ................................ .......... 251 Chapter 32 — Improving Patient Care Decisions ............................... 252 Outcomes management Clinical pathways Treatment protocols Double -blind peer reviewed studies Retrospective statistical analysis Boundary guidel ines Decision trees Outcomes audits Discussion Questions ................................ ................................ .......... 256 Chapter 33 — The Competition ................................ ............................ 257 Hospital systems Vertical integration Discussion Questions ................................ ................................ .......... 260 9 Chapter 34 — The Power of the Press ................................ .................. 261 Vi olation of HIPAA Di scussion One — Confidentiality ................................ ....................... 263 Key Provisions of HIPAA Discussion Questions ................................ ................................ .......... 265 Chapter 35 — Anniversary Dinner ................................ ....................... 266 Chapter 36 — Las t Official Act ................................ ............................. 270 Chapter 37 — Carnavali ................................ ................................ ........ 272 Chapter 38 — The B oardroom ................................ .............................. 276 Chapter 39 — SWAT Team ................................ ................................ ... 281 Chapter 40 — The Dedication ................................ ............................... 282 Epilogue ................................ ................................ ................................ . 285 Abbreviations Used in Text ................................ ................................ .. 287 Glossary of Medi cal and Administrative Terms ................................ 289 Index ................................ ................................ ................................ ....... 316 Order Info rmation ................................ ................................ ................ 320 10 Major Characters All characters are f ictional Dr. Paige Adams — Professor of Human Resource Management, Weber State University Dr. Ashton Amos — President of the Medical Staff, Board Member, Cardiac Surgeon Birdie Bankhead — Secretary to the Administrator David Brannan — Chairpe rson of the Board of Brannan Community Hospital, Son of James and Rachel Brannan, brother of Matthew Brannan James Brannan — Wealthy hospital benefactor, son of Peter Brannan Matt Brannan — Physician, Son of James and Rachel Brannan, friend of Amy Castleton Mi ke Brannan — First member of the Brannan Clan to settle Park City, Silver Baron Peter Brannan — Son of Mike Brannan, husband of Sara, hospital founder and benefactor Rachel Brannan — Wife of James Brannan, mother of Matt and David Brannan Sara Brannan — Wife of P eter Brannan, hospital founder Amy Castleton — Daughter of Hap Castleton Hap Castleton — Former Administrator of Brannan Community Hospital Helen Castleton — Wife of Hap Castleton Emma Chandler — Acting Controller , Brannan Community Hospital Del Cluff — Budget Director Tony Devecchi — Real Estate Developer and Entrepreneur Wes Douglas — Interim Administrator , Brannan Community Hospital Kayla Elmore — Health Occupations Students of America Volunteer Elizabeth F lannigan — Director of Nurses Dr. Emil Flagg — Physician and Board Member Thayne Ford — Newspaper Editor June Hammer — Chief Dietitian 11 Karisa Holyoak  Managing Partner, Hospital CPA Firm David Hull — Administrator , Snowline Regional Medical Center Helen Ingersol — Board Member Dr. Herb Krimmel — Health Economist, University Hospital Al Kuxhausen — FBI Agent Dr. Allison Lindberg — Medical Director, University Hospital Pete Lister — Director of Marketing, St. Matthew’s Hospital Peter O’Malley — Se rgeant, Park City Police Department Madeline McMillan — Utah Healthcare Association Director Martha Nelson — Paradigm Medical Systems Accountant Larry Ortega — Director of Reimbursement , University Hospital Ryan Ramer — Chief Pharmacist Dr. L indsey Reese — Nursing Professor Parker Richards — New Assistant Administrator , Brannan Community Hospital Liam Russell — President, Park City State Bank Roger Selman — Hap Castleton’s Controller Jerry Smith — FAA Investigator Charles Stoker — HMO Director, University Hospital Hank Ulman — Self Appointed Union Steward Jaxon White — Architect Arnold Wilson — Vice President, Park City State Bank Edward S. Wycoff — Chairperson of the Finance Committee of Brannan Co mmunity Hospital Don Yanamura  Human Resources Director, Brannan Community Hospital Barry Zaugg — Underworld figure 12 Acknowledgments Appreciation to the following who reviewed the book and provided helpful insight s: Denise Abbott, R .N., Instructor in medical anatomy and physiology, Timpview High School, Orem, Utah Steven Bateman, M.H.A . Administrator , St. Mark’s Hospital, Sandy, Utah Kristen Davidson, R.N., Instructor in medical anatomy and physiology, Northridg e High School, Layton, Utah : National President, HOSA 2008 Spencer Elmore , D.D.S., Colorado Springs, Colorado Mark J. Howard, Administrator , Mountainview Hospital, Las Vegas, Nevada Joseph McDermott, M.D., Pathologist , San Antonio, Texas Richard McDermott Jr., D.D.S., Orthodontist, St. Louis, Missouri Robert Parker, M.H.A., President, Emergency Physicians Inc. Christine Pounds , R.N. , Syracuse, Utah Lindsey Reese, R.N., Research and Editorial Consultant , Clearfield, Utah Candadai Seshachari, Ph.D., Emeritus Professor of English, Weber State University, Ogden, Utah Kevin Stocks, Ph.D., CPA , Professor of Accountancy, Brigham Young University, Provo, Utah De bie Todd, Kaysville , Utah Melissa White, R.N., Lakenheath, England 13 Preface hat you are about to read represents a new way of teaching technical material. As the approach is unorthodox, an explanation is warranted. The format is that of a textbook/novel. It tells t he story of an accountant asked to become the interim administrator of a failing rural hospital after the death of the hospital administrator. Before he can save the hospital, he must understand how the healthcare industry differs from other industries whe re he has worked. Why a textbook/novel ? I believe fiction is an effective tool for teaching technical material. For thousands of years, civilizations passed knowledge to succeeding generations through stories — folk tales, poems, myths, and epics that taugh t values to succeeding generations of their societies. Even the Bible — a reference for many cultures — is not a list of rules. It is a series of stories explaining what happens when people follow (or fail to follow) the concepts taught in the text. A well -wr itten textbook/novel can provide the following:  A smoother transition from school to the world of work. The author — a former hospital administrator — observed the cultural shock that occurs when students graduate from sch ool and enter the hospital. Trad ition al textbooks have difficulty portraying some of the more difficult issues employees face involving ethics, power, and politics. Code Blue is designed to soften the adjustment by giving students a simulated work experience in the healthcar e environment.  Learning in context . Students learn better when they can see how ideas taught apply to real -world settings. Instructors report that difficult ideas are more easily understood when an author immediately illustrates theory with examples .  Riche r classroom discussions . Fiction allows the instructor to interact with students in meaningful classroom discussions.

Discussions are more interesting than lectures , as they involve students in learning. Classroom discussions teach assertiveness, communica tion, and critical thinking.  Better integration of topics . Fiction gives instructors the opportunity to explain how issues like cost, quality, and medical ethics relate to each other. In a textbook/novel, students can see how professionals balance competi ng interests.  Exploration of ideas from different viewpoints. In the world of work, well -meaning people can look at the same data and come to W 14 different conclusions. Fiction allows students to explore diverse viewpoints through the eyes of those with diffe rent values, agendas, and backgrounds.  Conflict Resolution. A well -written textbook/novel shows conflict resolution in high -stress environments.  Instruction in critical thinking. Most textbooks are good at teaching students to find correct answers . They g ive the question, and supply all the data needed for the solution . Many fail, however, to teach students how to ask the right question. If you ask the wrong question, you are likely to get the wrong answer. Fiction can teach students to distinguish betwee n problems, and symptoms. A well -written textbook/novel teaches , that in the real world , there is often no t one right answer.  Experience in resolving ethical issues. In work, issues are not always black and white. As health costs consume an ever -increasin g share of the gross national product, our nation may soon face rationing of healthcare products and services. Is it better to spend scarce resources on prevention, or should it be spent on catastrophic care? Is it better to save money, or to save lives ? These are issues the next generation will be forced to address. Code Blue explains problems healthcare professionals face when reconciling cost, quality, and accessibility.  Increased communication skill. Code Blue give s students the opportunity to develop written communication skills by preparing memos on issues and events portrayed in the story. It adds life to what otherwise might be viewed as “dry writing assignments.” Code Blue also improves commu nication skills through presentations and role -playing exercises.  Increased Learning. Finally, education is more effective when it is fun. A murder mystery is more interesting than a traditional textbook. 15 TOPICS COVERED Topics covered include:  The histor y of the American healthcare delivery system  The history and theory of managed care  The Affordable Care Act of 2010 ( the Patient Protection and Affordable Care Act )  Pay for performance  An exploration of th e question: “Why are costs so high?”  An introduction to legal and ethical issues  Total quality management  The effect of technology on cost and quality  Legislation and regulation  Critical thinking and problem solving  The role of the professional  Hospita l organization  Power and politics in healthcare organizations  Teamwork  Systems  Cultural diversity  Discrimination  Quality, safety, and risk management  Medical and administrative terminology Supplementary Teaching Materials Supplementary questions at the end of chapters give the instructor an opportunity to test students’ knowledge. Test banks and PowerPoint slides cut preparation time. There is a PowerPoint lecture for every chapter with technical material.

Teachers can reproduce copies of the PowerPoint ha ndouts and give them to students as teaching aids. 16 Teaching Suggestions Code Blue was designed as a supplement. Educators have used it in a variety of courses to introduce students to current issues in healthcare. We recommend tea chers co ver the book in a three -to-six week period, preferably at the start of a course. They can then use the topics taught as a framework to build on when teaching from the primary textbook of the course. We strongly encourage instructors to allow students to re ad the entire novel , excluding discussion questions, before covering the chapters in class , as students become impatient to find out how the story ends. There are multiple ways to add structure to the course. One is to use the first 20 minutes of the class reviewing the chapter terms and theory using the PowerPoint slides. The instructor can then use the rest of the class period to discuss the questions at the end of the chapter. A second approach is to use the lesson plans on the CD. Code Blue is pre -professional reading. It includes some non -clinical material such as power and politics, ethics, managed care, and prospective reimbursement, all of which influence the way healthcare is practiced at all levels in the 21 st century. The author has tried to present the material in an interesting format. As with any topic, however, mastery of the material requires genuine study. 17 My goal in writing Code Blue was to increase learning by presenting technical material in a fun and entertaining manner. I encourage educators and students to e -mail me with questions or suggestions on how I can improve the textbook/novel and its supplements. I will be responsive to your suggestions. Richard E. McDermott, Ph.D. Professor of Healthcare Administration and Accountancy Weber State University [email protected] June 2013 18 1 ______________________________________________________________ Trip to McCall September 4, 1999 — Salt Lake City Inter national Airport t was 7:30 a.m. and the shadows of the Wasatch M oun tains blan keted runway three -four -left as a blue and white Cessna 340 pulled out of the hangar, rolled onto the taxiway, and stopped. The roar of the twin 335 horsepower engines severed the crisp morning air, resonating angrily off the metal buildings to the west. Inside the private aircraft, the pilot, Hap Castleton, pulled his flight plan from a dog -eared navigation book and studied it for the route that would take him to Twin Falls, Boise, and finally, McCall, Idaho. Hap had a broad, generous face, graying brown hair, and a large frame. Deep creases mapped a face that weathered the storms of 30 years as administrator of a small hospital in Park City, Utah. Satisfied with the flight plan, he gently nudged his traveling companion, Del Cluff, and trace d the route on the map with his index finger. Cluff, a thin man with receding brown hair, looked up from an accounting journal. His rooster like eyes pecked at the map momentarily.

Nodding at Hap, he returned to his journal. Hap had invited Cluff to discu ss changes in the finance department . The board was pushing for a major change in the way the hospital was being run, and finance was a good place to start . Hap folded the aviation map and placed it next to his seat. Picking up the mike, he contacted groun d control. “Salt Lake ground — Cessna two -six Charlie requests taxi to run way three -four -left.” “Cessna two -six Charlie — cleared to taxi.” Hap in creased his throttle, turning the plane onto the taxiway that would lead him to the assigned runway. The morn ing air was cool and the takeoff would be smooth. He tuned the radio to 118.3 — the Salt Lake tower. “Cessna two -six -Charlie re quests clearance for takeoff.” I Administrato r. The manager of the hospital. Finance department . The department responsible for accounting and finance within a hospital. 19 “Ce ssna two -six -Charlie cleared for takeoff. Fly heading 320, climb to one -three thousand feet, contact depar ture on 124.3,” was the tower’s reply. Hap felt the freedom surge deep within him as he released the brakes, pushed forward on the throttle, and star ted his takeoff roll. Flying and fishing were his favorite hobbies, but heavy responsibilities at Brannan Community Hospital made it difficult to find time for either. Today would be different. The plane accelerated. At 100 knots, Hap gently pulled back o n the control yoke . With a soft thump, the wheels left the runway and the plane lunged skyward. The plane climbed to 13,000 feet and turned onto its assigned heading of 320 degrees. Hap studied the altimeter and compass, checked his airspeed, and adjusted the trim. Satisfied the plane was on course, he turned his attention to Cluff . Del Cluff had been with the hospital for nine months. A meticulous accountant, he was a major source of irritation to Hap. It wasn’t just that Cluff was a bean counter, althoug h that didn’t help. Why anyone would want to spend his day with his nose buried in accounting records puzzled Hap. It wasn’t even the preference shown to Cluff by Edward Wycoff, chairperson of the finance committee , although anyone who could get along with Wycoff was suspect in Hap’s eyes. No — there was something more to it, something he couldn’t quite put his finger on. Grabbing a sack from under his seat, Hap nudged Cluff on the leg. “Something to eat?” Cluff managed a nauseous smile. Pointing to his stom ach, he shook his head — negative . Hap snatched a sandwich and took a generous bite, wiping his fingers on his flight suit. Nervous stomach? Cluff takes life too seriously, Hap thought. The smell of eggs and mayonnaise filled the cockpit. Chewing ferociously , Hap tuned his navigation radio to the next VOR as the plane crossed the first radio beacon .  From the right seat, Del Cluff watched the pilot adjust the radio and wondered why he accepted the invitation to fly with Hap Castleton. Hope thi s yo -yo knows more about flying than he does about hospital administration, he thought. Palms sweating , he tightened his seat belt. Hap’s management style was an increasing source of frustration to Del Cluff. He created more problems in a day than Cluff a nd a small flock of hospital accountants could fix in a month. Although his larger than life personality made him a hero to most of his employees, he was no hero to Cluff. The situation at the hospital was desperate. There were rumors the Board of Trustee s was planning a major change prompted by Edward Wycoff chair of the finance committee. For the past couple months Wycoff had been snooping around the department, reviewing records and quietly interviewing members of the staff. Altimeter . An instrument in the cockpit of an aircraft that reports the aircraft’ s altitude. Board of Trustees . A group of individuals who oversee the operation of the hospital.

The board of trustees has the authority to hire and fire the hospital administrator, approve the strategic plan and budget, and appro ve applications of doctors for membership on the medical staff. Chairperson of the finance c ommittee . A member of a hospital board who has responsibility for monitoring the financial health of the hospital. In Code Blue , Edward Wycoff has this responsibility. Finance committee . A committee of the Board of Trustees responsible for supervising the financial operation of the hospital. Radio beam . In the context of aviation, a beam emitted for navigation purposes. VOR . Acronym for very high frequency omni directional range. An aviation radio navigation system. Yoke . The “steering wheel” of an airplane. 20 The operation needed a good review, but Wycoff scared the wits out of most of the employees. His efforts only made things worse. The hospital was in dire straits . If it were a patient, it would be in cardiac arrest, in nursing terms — a code blue. Cluff folded his journal, slid it under his seat, and retrieved Hap’s navigation map. He studied it, and then squinted nervously at the hostile terrain below. To the north lay Mount Ben Lomond, capped with snow from a storm that moved through the Rocky Mountain s two days earlier. To the east, the cliffs of the rugged Wasatch Range reached skyward, thrust high by catastrophic earthquakes thousands of years ago. To the west, the frigid waters of the Great Salt Lake reflected the purple mountains of Antelope Islan d. Cluff shivered involuntarily. Folding the map, he returned it to the pocket by Hap’s seat. “Heard the rumors about Selman?” Hap asked, the irritation in his voice sawing the cold morning air. “Board’s pushing for a change — Wycoff plans on firing him Mond ay.” Hap worked his jaw — his habit when irritated. “As soon as Selman’s gone, Wycoff wants to install you as controller.” Cluff’s eyes, a good indicator of his emotions, jumped in surprise. Cluff would welcome a change — he and Selman often disagreed . He woul d even welcome the chance to run the department his way, but he wasn’t sure the promotion would be up — it might be out. Cluff said nothing while Hap struggled to control his anger. “Accept the job and you’ll get two new responsibilities.” Hap’s words were s hort and clipped. “The first is budget director — Wycoff wants three million dollars cut from the budget — I want you to oppose him!” Fat chance! Cluff thought. Half of our suppliers have us on a cash only basis; we aren’t even sure we can meet payroll. This wasn’t the first time Hap locked horns with Wycoff. He had no ally in Del Cluff. “The second . . .?” Cluff asked. “Project coordinator for a new accounting system.” The yoke of the small aircraft started to pull. Hap adjusted the trim. “Six months ago I a sked a consultant to look at the operation, see if he could propose something to cut losses. Insurance companies are killing us. The board isn’t going to allow me to take another contract until we have a better handle on our cost s.” Cluff smiled and nodded , his eyes narrowing with approval. “Our auditors have been after Selman for a year to get a system up and running,” Cluff said. “They think this should be our number -one priority.” Hap nodded decisively. “It’s now your number -one priority. Wycoff’s hired a CPA , a fellow named Wes Douglas, to serve as a consultant on the project. Wycoff wrote him a memo — read it.” Cluff smirked sarcastically. He’d seen the memo. Wes was an Eastern accountant and knew nothing about rural hospitals. He’d be more tr ouble than he was worth. Earlier that morning, Hap received a briefing at the weather desk. An unstable air mass with high moisture content from Canada had moved into Auditor . A person who reviews records to verify that transactions have been accurately reported. Budget director . The person responsible for preparing and monitoring the hospital’s budget. Cardiac arrest . A condition where the heart has stopped beating. Code blue . A distress call broadcast over the hospital intercom announcing to doctors that there is a cardiac arrest and that aid is needed. Consultant . An exp ert who has knowledge that an organization lacks.

Consultants are hired to provide this knowledge for a fee. Hospitals use many consultants as the medical field is complex and most hospitals cannot afford to employ full -time employees in every area in whic h expertise is needed. Controller . The individual responsible for managing the financial activities of a hospital.

Responsibilities include accounting, working with banks to borrow money, and supervising the collection of accounts receiv ables (amounts owed by patients who have received care but not yet paid the bill). CPA . Abbreviation for certified public accountant. A certified public accountant has passed an exam that shows a minimum level of knowledge in accounting and ta x. 21 the region, lifted high by the steep terrain of the Rocky Mountains. Severe thunderstorms were probable. Hap studied a dark bank of cumulus clouds at twelve o’clock. On his present heading he’d hit the storm head on. He fished in his shirt pocket for a note card, and then pointed to a scuffed manual on the floor. “I need a radio frequency — Tw in Falls localizer . Think the frequency is 122.4 but I’m not . . .” Hap aborted the sentence. Mouth wide open, he studied his instrument panel, then gaped out the window as his expression changed from disbelief to terror. Simultaneously, a cold wave of an xiety engulfed Cluff. “What’s wrong?’ he asked. “The right engine — ” Hap choked, the color draining from his face. A thin ribbon of blue smoke was trailing from the cowling . Hap reached for the throttle, but before he could cut power, an explosion rocked th e plane, whipping Cluff’s head so violently he could taste the pain. Hap grabbed the yoke in an attempt to regain control of the aircraft. “Fire!” Cluff screamed. The plane banked dangerously while Hap reached for the radio. “Mayday, Mayday, Mayday,” he shouted into the mike. “Cessna two -six Charlie, lost an engine . . . on board fire.” He glanced at the altimeter “Descending out of one -two -niner. Request immediate vector — emergency landing!” One engine dead, the Cessna pulled right, the centrifugal force created by the right engine threatening to pull the plane into a flat s pin. A spin would give the aircraft the flight characteristics of a pitching anvil — no lift; just spin, speed, and mass. “Can’t hold it!” Hap shouted, jamming his foot down on the left rudder. “Throttle back . . . cut the left engine!” Hap whispered to him self. He lunged for the throttles, accidentally cutting power to both engines. The plane shuddered — then dropped like a roller coaster. Unable to pull it out, Hap wrapped both arms around the control yoke. The veins in his neck protruded like steel cables a s he pulled with all the strength of his 250 -pound frame. At 280 knots, the burning engine separated, its broken cowling ripping the horizontal stabilizer from the tail as it cleared the aircraft. A side window blew out. Cluff grabbed for something to hol d on to — the ride down got rougher still. Still struggling with the yoke, Hap turned the plane north towards Highway 82. It was clear from the glide slope they wouldn’t reach it. An alarm sounded — red and amber lights exploded on the instrument panel. Heart pounding like a sledgehammer, Cluff gaped at the rapidly approaching terrain below. To the west, he saw homes and apartment buildings. To the east, nothing but the foothills of the jagged Wasatch Mountains. Direct in front lay a freshly harvested hay fiel d. Cowling . The shield or covering of an aircraft engine. Horizontal stabilizer . The short horizontal wing on the tail of an aircraft. Localizer . A transmitter used in an instrument landing system that provides the pilot with information regarding his alignment with the runway centerline during a landing appr oach. Vector . A magnetic direction used in aviation. 22 A farmer watching the plummeting aircraft jumped from his tractor and ran for cover. Cluff’s eyes desperately drank every detail of the approaching terrain as he searched for a way out. The field was flat — but too short for a landing. At the far end wa s an elementary school. Children were already playing in the yard, waiting for the morning bell to ring. Cluff pointed. “Try for the field!” “We’ll hit the kids.” “They’ll scatter.” “Can’t chance it . . .” This idiot’s gonna kill us! Hap banked the plan e east toward the foothills. Completing the turn, he dropped his flaps. An alarm sounded — the landing gear wasn’t down. Rough terrain — bring her in on her belly. To minimize the chance of a fire on impact, H ap turned off the electrical system. The blue and white Cessna, both engines silent, skimmed a row of cottonwood trees, the yoke heavy and unresponsive. As Cluff screamed in terror, Hap Castleton tightened his harness and braced himself for the crash. Discussion One --Comm unication “It takes two.” For communication to take place one person must create a message and another person must receive, interpret, and evaluate it. The person sending the message is the sender. The person receiving it is the receiver. A sender can use words (spo ken or written), pictures, or nonverbal cues such as facial expression, actions, and body movement to suggest meaning. The receiver responds to a message based on his or her perception of what the sender has said . Discussion Questions 1. From what you have read in chapter one, complete the following personality profile for Hap Castleton and Del Cluff. 23 Attribute Hap Castleton Del Cluff Focuses on details Focuses on the big picture Motivated by facts Motivated by feelings Focuses on the possible Motivated by dreams Analytic Sympathetic Interested in things Interested in people Inclined to gather a lot of information before making a decision. Inclined to decide quickly based on emotion ra ther than facts. 2. Why is it important to understand the values, personalities, and decision making model of a person you wish to communicate with? 3. It is obvious Del Cluff has not established a good rapport with his boss Hap Castleton. To what do you attribute this problem? 4. What are the differences in the ways Del Cluff and Hap Castleton process information, and therefore make decisions? 5. Given the differences in personality, values, and decision -making style, ho w could Del Cluff be more effective in communicating his concern about the hospital’s financial condition to his boss Hap Castleton? Writing Exercise 6. Assume you are Del Cluff. From what you know about Hap Castleton, prepare a written memo explaining yo ur concerns about the hospital’s losses. Explain why you will not oppose Edward Wycoff’s efforts to cut the hospital budget. 24 2 ______________________________________________________________ The Board dward Wycoff arrived at the hospital at 6 :30 on Monday morning — a half -hour before an emergency meeting of th e Board of Trustees . Exploding down the hall, he ignored the greetings of the housekeepers. Without breaking stride, he threw open the large walnut doors of the boardroom and switched on the lights. Throwing his briefcase on a sma ll telephone desk, he inspected the room. A retired officer in the Army Reserves, he knew how to conduct an inspection. Pity the employee who failed to meet his expectations! Consistent with his instructions, the housekeepers had vacuumed the carpets and p olished the conference room table until it shone like the brass on a general’s uniform. He picked up the phone and punched in the extension of the dietary department . The chief dietician answered. “Wycoff here!” His commanding to ne never failed to catch an employee’s attention. “I ordered breakfast for the board !” Telephone in one hand, the chief dietitian motioned frantically at a transportation aide with the other . The aide clumsily shoved the heavy cart toward a service elevato r. “Cart’s on the way, Mr. Wycoff. Would’ve been there earlier but — ” Wycoff hung up, unwilling to satisfy her with an explanation. For a moment, the room was silent as he admired his reflection on the marble surface of the boardroom table. His most disti nguishing features were his eyes  small and deliberate, the color of chipped ice. As always, he was unstirred by currents of self -doubt. Hesitate — even for a moment — and you’ll lose, he thought. Compassion now would only dull the victory . . .  Dr. Ashton Amos stuck his head through the door. At six -foot -one, he looked more like a basketball player than the newly elected president of the medical staff . His boyish mannerisms — coordinated awkwardness and large grin — made him popular with employees and doctors a like — a characteristic Wycoff would capitalize on. Chief dietician . A dietician is an individual who has been trained to use nutrition to treat illness. Dieticians work in the dietary department where food is prepared for hospital patients. The chief dietician is the supervisor of the dietary department. Dietary department . The department responsible for preparing patient meals. President of medical staff . An elected officer of the medical staff who represents the medical staff to the board and administra tion . Transportation aide . A person responsible for transporting food, supplies, or patients throughout the hospital. E 25 Weariness from a 28 -hour shift in the coronar y care unit lined Dr. Amos’ voice. “Got your message,” he said. “Just finished rounds . . . can talk now if you’d like.” Wycoff nodded. “Come in,” he said evenly. Dr. Amos crossed the room, seating himself in a large leather chair across from Wycoff. Pulli ng a clean handkerchief from his pocket, he wiped his face and then blew his nose. “Spent the night at the hospital?” Wycoff asked. The doctor’s mouth drew into a grim line. He nodded. “Fifty -one -year - old patient.” Removing his glasses, he slowly massaged his eyes. “Double bypass — complications.” Wycoff was unmoved. “Any word on Hap’s accident?” Amos asked, moving on to a new subject. Wycoff shook his head. “The plane hit 50 feet below the summit. Sheriff thinks they were trying to re ach Mountain Road. An FAA team arrived Saturday — I don’t think they know anything yet. Have you heard anything about Hap’s funeral?” “It’s scheduled for Monday — noon. I’ve canceled surgery.” Wycoff nodded. “What’s the report on Cluff?” Dr. Amos h ad emergency call the night they brought in Cluff. “Life flighted to University Hospital. Called his attending physician this morning. Listed in critical condition but they think he’ll make it.” The room was silent as Wycoff digested the information. The young doctor knew Wycoff hadn’t called him in to report on Del Cluff. Unless Wycoff needed Cluff’s services again — an unlikely probability considering the severity of his injuries — Wycoff would give no further thought to Cluff’s welfare. “What’s the board going to do about a new administrator?” Amos asked. Wycoff pursed his lips as though it was the first time he’d considered the question. “It’s been a difficult weekend for me,” he began, mouthing the words he so carefully rehearsed early that morning. “Hap and I disagreed — disagreed often,” he said, nodding in agreement with himself. “Still, I had a great deal of respect for the man.” Wycoff was lying . He had nothing but cont empt for the former administrator. He didn’t think Amos would know the difference. H e was wrong. Wycoff steepled his fingers, a gesture of authority he’d used with good effect on Wall Street. “I’ve spent the past two days agonizing over the best course of action for the hospital.” He hesitated. “I have a proposal, but I’m not sure if the board will buy it.” An ingratiating smile played on Wycoff’s lips as he leaned forward. He pointed a crooked arthritic finger at Amos. “I need someone with your prestige to explain it to them,” Wycoff continued. “Someone they respect, someone they’ll lis ten to!” Attending physician . The doctor who admits and supervises the care of a specific hospital patient. Coronary care unit (CCU ). The medical un it where patients with coronary (heart) diseases are treated and housed. Critical condition . The most serious classification of patient illness. Double bypass . An operation where two arteries are grafted to divert blood beyond an obstruction. Emergency c all. Physicians at some hospitals are required to provide coverage of the emergency room. This is referred to as emergency call. FAA . Acronym for Federal Aviation Administra tion . Life flight . A group that transports critically ill patients by aircraft to the hospital. Rounds . In this situation, the morning visit by a doctor to his or her patients in t he hospital. The term originated at Johns Hopkins Hospital in the late nineteenth century, where patient wings radiated off a central circular hall causing doctors completing their daily visits to do “rounds.” 26 Everyone knew how patronizing Wycoff could be when he wanted something. The thin layer of goodwill , however, failed to veil the cold rigor mortis of his eyes — the reflection of a thousand enemies ruthlessly eliminated. “It’s been my experience the board rarely turns down one of your recommendations,” Amos replied, his face masked and expressionless. “It’s essential the board pick the right man to replace Hap,” Wycoff continued. “It won’t happen overnight. While we’re interviewing candidates, we need an interim administrator . Someone strong enough,” Wycoff continued, “to fully implement managed care at Brannan Community Hospital.” Amos nodded, his face softenin g with relief. There were rumors Wycoff planned to bring one of his hired guns in from New York to run the hospital.

An interim administrator would be okay. It would give the hospital an opportunity to recover from the death of Hap while providing the time to organize the medical staff, if Wycoff still planned a takeover. “Candidates?” “None of our department heads qualify,” Wycoff replied. We need a financial man ,” Wycoff said with emphasis. Someone who can lead us through the current budget crisis.” “Wh o do you suggest?” Amos asked. “There’s a new CPA in the community — a fellow named Wes Douglas. The hospital hired him a few weeks ago for a consulting project. He has no preconceived notions and isn’t involved in hospital politics.” “Does he ha ve the time?” Dr. Amos asked. Wycoff nodded. “I phoned him last night. He’s still building his practice. He’s not only got the time; he needs the money.” Amos smiled. Wycoff could always identify a person’s vulnerabilities — he obviously found Wes’s. Dr. Am os rose thoughtfully and walked to the French doors overlooking the west patio. It was 7 :00 a.m. and the morning shift was arriving. Mary Hammond, a widow with six children was parking her car. Hammond worked as a clerk in the operating room. She pulled a lunch bag from the front seat of her battered Honda as she hurried off to her workstation. As Dr. Amos watched, he reflected on the effect closure would have on its employees. He turned to Wycoff. “I don’t have a better idea,” he said with a shrug. “I’ll s upport the recommendation. Of course, I can’t speak for the other members of the board .” Department head . Hospitals are complex organizations. To make them easier to manage, administrators organize them into departments, usually by function. There are clinical departments such as nursing and laboratory that pro vide medical services; and support departments such as medical records, administration , accounting and housekeeping that provide support services.

The supervisor of a hospital department is usually referred to as a department head or sometimes department supervisor. Department heads usually report directly to the hospital administrator, or in larger hospitals, to an assistant administrator . Interim administrator . A temporary hospital administrator who serves at the discretion o f the board until a permanent replacement is found. Managed care . An approach to cost control that includes preauthorization for expensive procedures, incentive reimbursement, retrospective (after -the - fact) quality audits, and second o pinions. Rigor mortis . The stiffening of the body that occurs after death. 27 Discussion One — Power and Politics In this chapter, we learn the reaction of the board to the death of the hospital ad ministrator. We also are introduced to power and politics in the hospital. Financial problems facing the board are also briefly discussed. Selecting a new administrator will be a difficult task. The board has several options :  Select an administrator who ha s been formally trained by an accredited progr am in healthcare administration and has experience in hospital management. If the Board of Trustees chooses this alternative, they probably will not be able to fill the job immediately . Any person they hire will have to give their present employer several weeks’ notice .  Select someone who has business experience , but no hospital experience, perhaps a local businessperson. The problem with this alternative is the issues involved in runn ing a hospital are different from those involved in running a retail, manufacturing, or construction firm. By the time the new administrator knows the rules, the game may be over.  Choose someone from the hospital to succeed the old administrator. This pers on would have the advantage of understanding the hospital’s problems. Department heads don’t always make the best hospital administrators, however. Many come from technical backgrounds and have little or no formal training in management.  Recruit a local do ctor to fill the job. A high salary and a lack of business training are the major disadvantages of this alternative.  Select an outside interim administrator who can guide the hospital through the current crisis and provide the Board of Trustees time to find a permanent replacement. The advantage of this alternative is the hospital will have someone immediately to address the financial problems the hospital is having. The disadvantage is that it is difficult to find a temporary admi nistrator with previous experience. The hospital staff will also have to adjust to two administrators (the interim administrator and his or her replacement). Discussion Question 1. What are the advantages and disadvantages of selecting an interim administ rator? 28 3 _____________________________________________________________ A Change of Seasons hirty -one year old Wes Douglas ste pped from his car to the sidewalk. He stretched the knots out of his back as he surveyed the wooded grounds of Brannan Community Hospital. The change of seasons had come suddenly this year. Colorful leaves blanketed the lawn like the patchwork quilts sold in the gift shop. Wes enjoyed all the seasons, but Fall — the season of change — was his favorite. As he watched a gust of wind stir the colored leaves, he pondered the changes awaiting him. Wes stood with Hap Castleton on this very spot in mid -September. Hap explained the crisis that motivated him to hire Wes as a consultant. The Board of Trustees was concerned the hospital was losing money. They blamed it on managed care, a program designed by insurance companies to control cost. Hap asked Wes to design a new information system that would allow the hospital to track their cost. For the consulting engagement, the board agreed to pay Wes $50,000. Although Wes spent less than a week working with Hap, the administrator impressed him with his energy and enthusiasm. Hap was an extrovert. His expressive style won the admiration of employees and medical staff. Hap understood people and was a master at hospital politics. He was weak, however, in operations, an area where Wes excelled. At Lytle, Morehouse, and Butler, his former CPA firm, Wes consulted with a host of manufacturing firms and helped design over a dozen accounting systems to control costs. Wes had a mind for detail. He was also a workaholic. Long after the staff went hom e, Wes pored over production reports and product flow diagrams, identifying inefficiencies that slowed production and raised cost. Wes reflected on the difference between himself and Hap Castleton during his first interview with Edward Wycoff, and Dr. Lin dsey Reese, a former nursing professor who now worked for the Joint Commission on Accreditation of Health Organizations . Since Dr. Reese traveled extensively, she could choose where she wanted to live and had settled in Park City. The three had finished dinner and retired to a richly paneled lounge on the second floor of the Yarrow Inn. Joint Commission on Accreditation of Healthcare Organizations (JCAHO ). An orga nization that accredits hospitals and other healthcare organizations.

Accreditation provides legitimacy in the eyes of the consumer, who is often unable to judge the quality of healthcare services. T 29 “I want to tell you a story,” Wycoff said, lighting a cigar as he settled into a large wing back chair. “One of my neighbors in New York, a fellow na med Eric Rose, was vice president of General Electric. When he retired, he had 30 years with the company. Four of the company’s officers retired at the same time — three vice presidents and a director. Thanks to General Electric’s generous retirement plan, t hey retired wealthy men, certain of their business ability.” Wycoff removed his glasses, placing them on a table by his chair. “Wes, sixty -five is too young to do nothing,” he said. “After long vacations, Eric and the three other officers started business es of their own. They were filled with confidence.” Wycoff paused for emphasis. “In three years, each lost his investment! One of them even took out bankruptcy . For a long time, I wondered why people who ran a billion dollar corporation couldn’t succeed w ith their own company.” His eyebrows rose inquiringly and he pointed his cigar at Wes.

“Want to guess why they failed?” Wes shrugged. “Inexperience in a new industry?” “That contributed, but I think the main reason was they no longer had the support and d iscipline of a team . At General Electric, the vice president of research had the vice president of marketing to remind him he had to develop a product that would sell. The vice president of marketing had the discipline of the vice president of engineering to assure he wouldn’t sell a product they couldn’t build. “The manufacturing vice president had the vice president of finance looking over his shoulders, urging him to cut cost so he could price the product at a level the customer could afford. The vice pr esident of finance had the other three vice presidents to remind him without marketing, engineering, and research, none of them would have a job!” Wycoff smiled reproachfully. “My friends failed because they chose partners that were just like them — not only in experience, but in aptitude.” “They failed to select people who could compensate for their blind spots,” Wes affirmed. ”That’s why I’m interested in your experience.” Wycoff pressed his lips into a fine line as he studied the young consultant. Wycoff leaned forward as though he was going to share a secret. “I’ll admit Castleton is great with people,” he whispered, “but he’s poor with details.” He shook his head . “Spend a little time with him, for example, and you’ll learn he knows nothing about finance . He couldn’t balance his own checkbook if his life depended on it. ” Wycoff continued: “Hap understands hospital politics, but you understand management and cost control. Alone , neither of you could run a business as complex as Brannan Community Hospital. As a team , however, I think you’d be unbeatable!” Bankruptcy . A situation where a person or organization is unable to pay its bills. Often in bankruptcy, the court seizes the bankru pt person’s or organization’s assets and sells them to pay creditors (the people to whom debts are owed). 30 Dr. Reese didn’t care for Wycoff much — he puts too much emphasis on money she thought. She had accepted the dinner invitation to interview Wes only out of her interest to the community in which she lived. While she wasn’t on the board , she followed its activities closely through articles in the newspaper. “I agree with Wycoff’s concern about the financial condition of the hospital,” Reese said. “But we have other problems as well, problems I think you could help us with. “I haven’t talked with Wycoff about it, but I think he ought to hire you as a permanent consultant to the board . I see your experience helping the clinical staff in a whole host of areas. ” She pulled a list from her pocket. “The first is quality assurance,” she said. “Continuous quality improvement is a big issue in manufacturing where the Japanese are cutting the American’s grass. Just look at the beating Ford and General Motors are taking from Honda and Toyota. “Admini stration and the board know almost nothing about the subject,” Reese continued, “and the hospital employees know even less.” She cocked one eyebrow. “Any idea of how you compare on issues of morbidity and mortality when compared to hospitals in Salt Lake C ity?” she asked Wycoff. Wycoff shook his head to the negative. “Neither does anyone else,” she replied. “Patients need more information on quality and cost, and we give them neither.” Dr. Reese turned to the second item on her list. “There are legal issues relating to the delivery of care that I think you could help us with,” she continued. “Ever heard of HIPAA or EMTALA ?” she asked. The question drew a blank stare from both Edward Wycoff and Wes Douglas. “Administration is doin g nothing to educate nurses, respiratory therapists and the like on issues that could cost you hundreds of thousands of dollars in lawsuits. I know you’re not a lawyer, Wes, but CPAs are accustomed to working with regulations, and where you don’t kno w the answers you can get them. “Diversity is another issue you’ve ignored,” she said, directing her comments to Wycoff. “To a financer , diversity means carrying more than one credit card,” she said sarcastically. The jab was not lost on Wycoff who shot an abras ive scowl. “Park City is somewhat of an isolated place,” she continued. “People here know nothing about the cultures of people who are moving here from all parts of the globe. You need to be more sensitive to patient’ s cultures when providing care. “Risk m anagement ,” Dr. Reese said pointing to the next item on her list. “You know what that is?” Wes nodded. “I installed a new program in a plant in Hartford, Connecticut.” Continuous quality improvement (CQI ). An approach to providing products that stresses that the organization should never be satisfied with its product —that ways should be found to constantly improve quality. EMTALA . Acronym for Emergency Medical Treatment and Active Labor Act , also known the Patient Anti -Dumping Law . This law is designed to keep hospitals from transferring patients who cannot pay for their care to other hospitals. Heavy fines are involved for those who do. HIPAA . Acronym for the Health Insurance Portability and Accountabili ty Act . HIPAA was enacted by the U.S. Congress in 1996. One objective is to protect confidentiality of health information. Morbidity . The number of cases of a specific disease in relation to the general population. Mortality . The hospital's death rate. The number of hospital deaths divided by the number of people in a specific population. Quality assurance . Procedures taken to assure a high degree of excellence. Risk Management . A department or specialty that anticipates and tries to prevent risks to employees, patients and visitors. Slipping on an icy sidewalk would be a risk this program might address. 31 “Big issue in healthcare,” Reese said. “Except for here. I’m not sure that anyone at Brannan knows what it means.” Wycoff nodded. That was one issue he agreed with. A poor risk management program could cost the hospital millions of dollars.” “You see,” Lindsey Reese continued, “we have students coming out of professional programs that think that all they have to know is the clinical side of medicine. While our clinicians are busy providing patient care, they have let the administra tors, lawyers and accountants assume the role of running the system. Unless clinicians re -involve themselves in the management of hospitals, we are going to lose the entire health care system. It will be one huge corporate or governmental bureaucracy.” “An d they can’t do that unless clinicians know more about the issues you are discussing,” Wes affirmed. “Right — but presently they lack the knowledge and training.” The room was quiet while Wes absorbed Reese’s message. After an appropriate pause, Wycoff insis ted on the last word. “The final item we need your help on is finance and accounting,” Wycoff said. We are four weeks or less from not meeting payroll — no payroll, no hospital.” Standing now on the front lawn of Brannan Community Hospital, two weeks after t he first conversation, Wes realized the proposals were no longer relevant. Hap was gone, and without him, there was no team, and without a team, there was no contract. Forcing a smile, he picked up his briefcase and crossed the lawn, entering the hospital through the large brass doors of the visitors’ lobby.  A row of wooden chairs with straight, upright backs stood sentry at the entrance to the lobby, and the scent of ethyl alcohol and cresyl violet seeped into the hall from the small laboratory on the first floor. Wes’s leather -soled shoes squeaked on the highly waxed linoleum floor as he crossed the lobby to the information desk. He spoke briefly with the receptionist, and then went directly to administration where Birdie Bankhead, secretary to the ad ministrator, greeted him. Birdie, a 56 year -old divorcee, had worked at the hospital as long as Hap. She looked up from the newspaper. Hap Castleton’s picture was on the front page. Wes noticed her red eyes and splotched cheeks. “I’m Mr. Douglas,” he said softly, “I’m here to meet with the board .” Birdie nodded in recognition. “They’re running a few minutes late. Would you care for some coffee while you wait?” “No, I’m fine.” Birdie wiped the corners of her eyes with a handkerchief. She opened her purse a nd retrieved a small makeup compact. “Sorry,” she said as she Administration . The department responsible for the management of the hospital. The hospital administrator heads this department. Cresyl violet . A dye used in staining slide specimens to be examined under a microscope. Ethyl alcohol . Synonymous with rubbing alcohol. It is often used as a disinfectant. 32 excused herself. “It’s been a difficult morning. I’ll be gone for a few minutes. If you need anything, Mary Anne in the next office can help.” Wes nodded as Birdie left. Hands in his pockets, he scanned the room. The office was 20 feet square and served as the reception area for the administrator’s office and the boardroom. The door to the boardroom was slightly ajar, and from the conversation drifting through the door, he could tell the meeting was winding down. A woman was speaking. “I’m not sure there’s anything we can do but what you suggest,” she said. “While I don’t like it, you’ve convinced me it’s our best alternative.” “All in favor?” a male voice said. There was a volley of “Ayes.” “T hose opposed?” There was one vigorous voice of dissent.  The door to t he boardroom opened wide, and Dr. Ashton Amos emerged, extending his hand in a generous greeting. Wes shook it as the doctor apologized for the delay. “Hope you haven’t been here long,” Amos said. Wes shook his head no and Amos gestured for him to enter th e boardroom. Inside, four members huddled in quiet conversation around a large conference table. Octagon in shape, it was cut from a one -inch slab of white Tennessee marble. It rested solidly on a square platform of polished walnut.

In the center stood an architect’s model of the new hospital Hap Castleton hoped to build — a project canceled just three days before his death. “I don’t think you’ve met the entire board,” Amos said as his eyes swept the room. This is David Brannan, chairperson of the board .” Dr . Amos pointed to a well -dressed man in his early thirties. Amos ginned. “From his last name, you can tell his family has played an important role in the history of the hospital.” Wes smiled in acknowledgment, while Brannan stood and shook his hand. “Next to David is Dr. Emil Flagg, the medical staff’s representative on the board .” Dr. Flagg, a pathologist in his early sixties, had a dyspeptic smile and smelled vaguely of formaldehyde . Stretch wrinkles radiated from the single button of an enormous white l ab coat that struggled to corral his rotund torso. Flagg glowered as he scanned Wes from head to toe, and gave a brief nod. “Helen Ingersol, president of Ingersol Construction is next. This is Helen’s first meeting with the committee.” Helen Ingersol, a st rong administrative type with short brown hair and piercing blue eyes, smiled acknowledgment. “And last, but not least, is Ed Wycoff. You already know Mr. Wycoff.” Wycoff motioned for Wes to take the chair next to him. “The tragic events of the weekend ha ve forced us to come to some difficult decisions,” Wycoff said, his lips compressing into a cold, thin line. Chairperson of the board . The person appointed to lead the board . The chairperson usually sets the board agenda, appoints committees, and represents the board to the administrator and medical staff. Formaldehyde . A pungent gas used as an antiseptic and disinfectant. Pathologist . A medical specialty focusing on the diagnosis of disease through changes in tissues. 33 “As these involve your consulting contract, we felt we should involve you in the discussion.” Wycoff paused. “Before addressing the issue, however, we have one other item of business. Dr. Amos, would you invite Roger Selman in?” As Amos left the room, Wycoff turned to Wes. “Roger is the controller ,” he whispered. In the summe r before college, Wes worked for his grandfather, herding sheep to the mountain pastures. Sometimes dark thunderheads appeared on the horizon, churning their way toward the summer pasture. Even though the air was deathly still, an unfathomable uneasiness p receded the pyrotechnics soon to come. That same atmosphere filled the room as Amos returned with Selman. Each took their seats  Amos next to Wycoff, and Selman next to Wes Douglas. Except for the drumming of Wycoff’s fingers on the cold marble table, the r oom was silent. Wycoff studied the concerned face of each board member. Satisfied he had their attention; he removed the hospital’s financial report from a manila folder and carefully placed it on the table. He gazed at it for a moment, quickly withdrawing his hands for dramatic effect. “Lady and gentlemen,” he said with a theatrical flair, “Mr. Selman has provided us with an unusual document! In my 20 years as a financial analyst , I have never seen anything like it.” He paused for emphasis. “You are to be congratulated, Mr. Selman!” Wycoff’s sarcasm was not lost on Selman who squirmed uncomfortably in his chair. “Mr. Selman, when you joined the hospital five years ago, we had a successful business. No debts — one million dollars in the bank.” Wycoff took a d rink of ice water, and then wiped his mouth with a handkerchief. Beads of perspiration formed on Selman’s forehead. With a beefy forefinger, he tugged on his collar, loosening the knot of his necktie, which seemed to tighten even as Wycoff spoke. Wycoff’s eyes narrowed. “The report given this morning shows a substantial reversal,” he said glacially. Still staring at Selman, he methodically flipped — one by one — through the pages of the report. “During the previous twelve months,” he continued, “we produced a loss of three million dollars. Monday morning, our borrowing reached two million dollars, taking us within $150,000 of our credit limit . With less than $150,000 of cash in the bank, we are dangerously close to not being able to meet payroll. Why, Mr. Selm an,” he said with obvious sarcasm, “you and your associates have taken us to the edge of bankruptcy!” The room seemed to hold its breath as no one spoke . After a long pause, Helen Ingersol, president of Ingersol Construction spoke. “I’m not an accountant,” she began, addressing David Brannan, “but this is the first time I’ve seen the hospital’s financial report, and there are a couple of questions I need answered before I decide if I’m going to remain on the board .” Credit limit . The maximum amoun t, as determined by the bank, an individual or firm can borrow. Financial analyst . A person who earns his or her living by studying the financial statements of companies and making recommendations, often about investments. Financi al reports . Reports that show the financial condition of a firm. The three most common financial reports are the income statement, the balance sheet, and the statement of cash flows. The income statement shows revenues minus expen ses. The balance sheet lists assets (items that have economic value), liabilities (debts), and owner equity (the value of the owner’s investment in the firm). The statement of cash flows shows cash that has been received and disbursed by the firm during th e accounting period. 34 “Shoot,” Brannan said. “Mr. Selman, your reports show the hospital’s volume is up, but so are its losses. Your costs haven’t risen dramatically — in my business, this would signal a pricing problem. How do your prices compare to those of your competitors?” “We aren’t sure,” Selman replied. “Our com petitors don’t publish their prices. Even if they did, it wouldn’t matter. We work with over twenty insurance companies. Everyone pays a different price.” Ignersol gave a tenuous frown, unable to comprehend twenty different billing systems. “But what about your costs?” she asked. Are they competitive? “Don’t know.” Selman replied. “Our competitors don’t publish their costs.” Wycoff interrupted. “That’s understandable, we don’t’ publish ours either” he said. “What isn’t understandable is we don’t even know w hat they are.” This was a different business than anything Ingersol had ever encountered. “How is that possible?” she asked. “Our accounting system tracks costs by department, but not by product,” he said. Wycoff cut him off. “The problem isn’t accounting !” he shouted. “The problem is management! You don’t plan. You spend your time putting out fires.” “Actually Mr. Wycoff,” Selman said, breaking in. “Don’t interrupt me!” Wycoff snapped. “The reputation of the hospital is plummeting. Employee morale is low , productivity is lower, and service is rotten. I can’t attend Rotary without someone jumping me about some problem they had with the hospital. I’m fed up with it!” he shouted angrily. “Eighteen months ago,” Wycoff continued, “I opposed bidding on the Moun tainlands insurance contract without cost data,” Wycoff continued. Hap Castleton moved ahead anyway — on your recommendation!” “If we hadn’t bid the contract, we would have lost the business to competitors.” Selman replied. “I don’t know if we could have su rvived the drop in volume.” “There’s much you don’t know!” Wycoff replied sarcastically. From the expression on their faces, it was obvious the board was not comfortable with the caustic approach Wycoff was taking. Still, no one spoke. Roger Selman took a deep breath and released it slowly. “It’s been a difficult year,” he admitted, “but the worst is behind us. Yes, we’ve lost money, but we can fix the problem. That’s why Wes Douglas is here, isn’t it?” Breaking the lock of Wycoff’s gaze, Selman shot a pl ea for help to David Brannan. David had always been more sympathetic than the rest. 35 “Give me three or four months,” said Selman, “and you’ll see a dramatic change in our position.” Wycoff slammed the table. “We can’t survive that long! For the past three years, the hospital’s financial strength has plummeted. Although we can’t hold you solely responsible, your inability to provide cost information has crippled our ability to run the hospital.” Wycoff’s voice lowered as he sighted in on Roger Selman for the final kill. “Mr. Selman,” he said, “with the death of Hap Castleton, we have decided to reorganize your department,” he said. “As a part of the reorganization, we are asking for your resignation.” Wycoff forced his lips into a glacial smile as his voice d ropped “If you don’t resign,” he said barely above a whisper, “I will personally fire you.” Selman gasped as though he had been hit in the abdomen. He scanned the faces of the board , searching for any sign of support — none was offered. Denied a reprieve, he settled back in the large leather chair. In a minute or so, the tight lines around his mouth relaxed as fatigue replaced shock. Roger Selman was 62 -years -old — and he was tired. He was tired of fighting administration and the board . He was tired of running a department with few resources. Most of all he was tired of the long hours it took to fix the problems created by well -meaning but inefficient Hap Castleton. His emotions surprised him. He was no longer angry; he was relieved. Without Wycoff, I might li ve another ten years, he thought . The money isn’t important. I can find another job; maybe I’ll even start enjoying life again. Selman turned to Wycoff, who watched the transformation with quiet curiosity. Selman decided to give a speech he had rehearsed often but never found courage to deliver. “The world has changed, but the board is still living in the 1960s,” he started. “Healthcare is no longer a charitable enterprise — it’s a business. For five years I’ve told you we need a new accounting system — somet hing that will allow us to bid intelligently on insurance contracts while giving our supervisors the information they need to control their costs.” Now Roger Selman addressed his comments primarily to Edward Wycoff. “It’s the board ’s responsibility to prov ide direction and control. You provided neither. You failed to respond to a changing environment, and the hospital’s reaped the consequences. “The doctors complain about inefficiencies,” Selman continued, turning to Flagg. “But most doctors haven’t got a c lue about what it takes to run a hospital profitably. You talk about teamwork and unity, but the medical staff can’t agree on even the most mundane issues. “The hospital is in trouble,” Selman continued. “But firing me isn’t going to fix that. The hospit al needs change, but it is doubtful this will happen as long as you dinosaurs are in control.” Wycoff stiffened, obviously insulted. Roger Selman straightened himself with dignity. He folded his papers and stuffed them into the large envelope he had carrie d into the meeting. 36 Standing, he shook his head in quiet disgust at Wycoff, and then crossed the room. “Welcome to the 21st century,” he said as he shut the massive walnut door behind him. The room was silent as board members studied one another, uncertai n how they felt about Wycoff’s action — or Selman’s response. Before anyone could respond, Wycoff spoke. “Mr. Douglas,” he said, “ the board has empowered me to offer you a contract to serve as interim administrator of Brannan Community Hospital — only until we find a permanent replacement. We know you’re not a hospital administrator, but you have had some experience with the hospital, and right now we don’t have many other candidates. Wes looked up in surprise . Interim administrator ? Unwilling to speak until he thought the offer through, Wes studied the board members. In the two weeks Wes worked with the hospit al on the projects Wycoff outlined, he had lost much of his enthusiasm for Edward Wycoff. Wycoff would be a difficult person to work with. On the other hand, Wes had consulted with other small firms in trouble and enjoyed the challenge. His practice was sm all, and he did have the time. If he was successful, it might lead to future consulting jobs in the community. Accepting the assignment would be a good way to increase his visibility in Park City. “I think we can work something out,” Wes said. “I’m prepare d to offer you $5,000 a month for six months,” Wycoff said. Wes did the calculation in his head. “That’s about $30 an hour. My consulting rate is four times that.” Wycoff shook his head with firm determination. “The hospital’s in trouble, Wes. We can’t aff ord that. Five thousand a month is our best offer, guaranteed for six months if you perform to our expectations — longer if it takes more time to get a permanent replacement.” Wes thought about his new accounting practice. He only billed 28 out of a possibl e of 160 hours last month. In a week or so, he could complete his current jobs and sublease his office. He turned the offer over in his mind. His eyes softened and he settled on a decision. “I accept,” he said. Wycoff smiled smugly as he sank back into the large wingback chair. Expressions of the other board members ranged from happiness, to relief, to despair. David Brannan broke the silence. “I don’t mean to change the subject, Ed, but I have a meeting downtown in 20 minutes. Do we have enough cash to mee t the payroll Friday?” “I spoke with the Business Office last night.” replied Wycoff. “They’re expecting a $400,000 payment from Medicaid . . . should arrive by Wednesday. With that, and our remaining line of credit , we should be able to s queak by.” “Any chance it won’t be here in time?” Brannan queried. Interim Administrator . A temporary hospital administrator that serves at the discretion of the board until a permanent replacement can be found. Line of credit . Many organizations need to borrow money to meet short -term obligations. Supplies must be purchased, and employees mus t be paid before payment for the services provided is received from the patient or insurance company. A line of credit from the bank is designed to temporarily provide these funds. Medicaid . A governmental program funded with state and federal funds to provide healthcare to the poor. 37 “If it’s not here by Wednesday, I’ll drive to Salt Lake City and walk the check through their accounting department myself,” Wycoff said. He had done that before. “If payroll is covered, th en I suggest we adjourn,” said Brannan, smiling with relief. “Do I have a motion we adjourn?” “I so move!” said Dr. Ashton Amos.  It was evening when Wes entered the administrator’s office for the first time since assuming the job. No one had touched it since Hap died. He gazed at Hap’s personal items — family photos, a dusty rainbow trout, and a pair of running shoes — and remembered his last visit. Hap’s beaming personality permeated the room like the rays of sun that poured in through the French doors beh ind his desk. It was different today. The forest green drapes were drawn, and except for the light from a small corner lamp, the office was dark and tomblike. Wes turned on the lights, opened the curtains, and settled into the large green armchair facing the desk. The administrative wing was empty and he was grateful for the silence. Had Wycoff asked him, Wes would have opposed firing Roger Selman. Even if the controller was incompetent, he took with him knowledge and experience that would have been helpf ul to a new administrator. Besides, firing hospital personnel was the job of the administrator, not the board . Wycoff had overreached his authority. Wycoff justified himself by telling others the action was inevitable. “I was just wiping the slate clean,” he bragged, “taking care of a dirty job so Wes wouldn’t have to handle it.” Although Wycoff’s intent may have been good, it clearly backfired. The employees liked Selman. His dismissal, so soon after Hap’s death, shocked some and offended most. This hostil ity was evident at a meeting held later that morning when Wycoff introduced Wes as the new boss. As Wycoff told of the dismissal of Selman, two women employees on the front row cried, and a supervisor stormed from the meeting . It was true that three depar tment managers introduced themselves after the meeting in an attempt to be friendly , but it was also obvious that most blamed Wes for the firing of Selman. If Wycoff planned to set me up to fail, he couldn’t have a done a better job , Wes thought. Wycoff wa s not well tuned to the sensitivities of other people. The word on the street was he was bright, but ruthless. Wes’ thoughts were interrupted as Birdie Bankhead, secretary to the administrator, entered the room. She carried a large yellow envelope which she handed to the new administrator. Wes looked up in surprise. “I thought you left for the day,” he said. 38 “I did,” she replied. Birdie’s lips were drawn tight, a signal to Wes that she was struggling with pretty stron g emotions. “This is the first year we are applying for accreditation , however, and the application needs a signature.” As he opened the envelope she continued. “The application has to be in Chicago by Friday.” “Sign here,” she said pointing to the bott om line, “and I’ll drop them by the post office tonight.” He signed them and handed them back. She snatched them with hostility , not apparent before Roger Selman’s dismissal. Her eyes glistened as they caught the picture of Hap’s family on the desk. “You’l l want Hap’s belongings out of your office ,” she said stiffly. “ I’ll remove them tomorrow.” “There’s no hurry,” Wes said waving the comment off. “Let his family do it — at their convenience.” Birdie studied Wes through the cobwebs of reddened eyes. She hadn ’t slept for two nights, or maybe she was asleep still . This week was a living nightmare. From deep inside, a mournful sob shook her frame. Wes stood up and took her hand. “Listen Birdie,” he said. “I don’t agree with everything that’s gone on. Let’s not r ush the family. I can work around this stuff for a few days.” Observing Wes’s sensitivity, the lines around Birdie’s eyes softened. I wonder if he knows what he’s got himself into, she thought . At first Birdie hadn’t understood why the board hired someone with no experience to take the reins from Hap. She was starting to suspect it was to take a fall — deflect the blame from Wycoff and the board if the hospital folded. Her sympathy rose as she contemplated the consequences of failure for this naïve new admini strator. She took a deep breath and released it slowly. “I’m sorry about the reception you got at the meeting,” she said, starting anew. “The employees are good people. They’re still in shock over Hap’s death, and now with the firing of Roger Selman — .” Wes nodded. “I understand,” he said. “I’m not happy about the way things were handled today.” He smiled weakly. She smiled sadly in return. “Is there anything I can do before leaving this evening?” she asked, nodding at a pile of mail on his desk. “I’m flying to Seattle to complete a consulting assignment,” he replied. “Watch over the department while I’m gone.” “When will you be back?” “I told the board I could start a week from Monday.” Birdie raised her eyebrows in contradiction. “There’s a phone call fro m Wycoff that might change your plans,” She crossed to his desk where she tore a phone message from a notepad. “Mr. Wycoff called an hour ago. The bank is calling the hospital’s line of credit. Without it the hospital can’t meet payroll.” Wes looked up wit h a start, and then shook his head in disbelief. Accreditation . An evaluation by an official organization to assure that another organization meets mini mum standards of quality. In healthcare, accreditation is an activity conducted by a group named the Joint Commission on Accreditation of Healthcare Organizations . Since patients are usu ally unable to judge the quality provided by a hospital, accreditation is designed to guarantee that the hospital provides a high level of care. 39 She continued. “And did you see tonight’s paper?” she continu ed, handing him the evening edition of the Park City Sentinel. The headline read :

Hospital Employees Threaten Walkout Vote “no confidence” on appointment of new administrator Wes blinked with bafflement as he read the lead article. Removing his glasses, he rubbed his eyes, and then stared out the French doors. Dark storm clouds were rolling in from the West. Deep in thought, Wes reviewed his options. Finally he spoke, each word heavy with the responsibility he had unwittingly assumed. “Cancel my flight, ” he replied. Discussion One --Employability Skills Wes Douglas interviewed for a new job. The Board of Trustees interviews potential candidates and selects the winner. What do employers look for in hi ring a new employee? Surveys reveal the following characteristics :  Ability to do the job  Ability to get along with people  Willingness and ability to fit the corporate culture  Integrity and loyalty  Adaptability to change Ability to do the Job High in priority for any employer is the ability of the employee to perform the tasks needed by the job. Before interviewing applicants, employers often prepare a job description , giving the title of the job, the place of employment, who th e employee reports to, and a list of tasks the employee must complete to perform the job successfully. Job description . A document detailing a position’s: (1) job title, (2) salary range, (3) reporting line, and (4) duties. 40 Aptitude Aptitude is defined as “ natural talent, an ability to learn easily and quickly, a set of factors that employers can assess that show what occupation a person is best suited for. ”1 Different people have different aptitudes. People with strengths i n one area often have weaknesses in another. A good mathematician may be a poor writer. An able mechanic may have poor people skills. Before selecting a career, one should research the aptitudes needed for the specific job. A dentist, for example, needs m anual dexterity and good people skills. Some people spend years qualifying for an occupation, only to find after graduation that they don’t enjoy the work or its environment. How does one avoid making a mistake when selecting an academic course of study?  Talk with people who work in the industry. Ask them what they do during a typical day. Ask about their work environment , the type of people they associate with, the aspects of the job they find enjoyable, and the aspects they find b oring or distasteful.  Work in the industry before seeking a degree in a specific field. Many medical schools, for example, encourage students to work as Certified Nurse Assistant s (CNAs), before applying to medical school.  Take a vocational aptitude test . Education and Training Many professional jobs need licensure or certification . Professional associations like the American Medical Association , the Am erican Nursing Association , and the American Hospital Association can help identify requirements for a specific profession. In addition, most healthcare jobs require some college or technical school education. Realize, however, knowledge is expanding at an ever -increasing rate. Much of what you learn in school will be obsolete within 15 years of the time you get your degree. Continuing education is a requirement for most professions. 1 The New Lexicon Webster’s Dictionary of the English Language , Lexicon Publications, Inc. Danbury, Ct. Aptitude. Natural ability. Certification . Recognition by a nongovernmental regulatory body that a per son meets minimum standards to provide healthcare services. Licensure . Official recognition by a governmental body that a person meets minimal educational requirements, and has the knowledge and skill to practice a specific profession. 41 Experience Some employers want real -world work experience before they hire an applicant. One way to satisfy this requirement is through an internship . Check with a local college to see if they offer internships. Ability to G et Along with People Another important characteristic employers look for is an ability to work with people. The most common reason people are fired is not technical incompetence, but an inability to get along with p eople. Most work in the healthcare industry is done in teams. The ability to work in a team takes skills sometimes not taught in high schools and colleges. These include:  An ability to identify the goals of the team, and to put these ahead of personal age ndas.  The ability to take responsibility for a specific task and complete it without supervision or prodding.  The ability to communicate; to understand other people’s points of view; and to compromise.  The ability to coordinate time schedules.  The ability to coordinate tasks with other people.  A willingness to share credit for a job well done. Ability to Fit the Corporate Culture Corporate culture is defined as “what behavior is acceptab le at our place of work.” A corporate culture defines the dress code, codes of conduct, and so on. The corporate culture varies from company to company. At one time t he corporate culture at IBM mandated a white shirt, blue or gray suit, and a conservative tie. At Microso ft the corpo rate culture permitted t -shirts and sandals . How do you know when an organization is “a good fit?” One way is to visit the firm before applying for the job. Another is to talk to employees about the culture, expectations, environ ment, and so on. Integrity and Loyalty Studies have shown that many firms favor loyalty above honesty. Both are important. Internship . A training program, usually one or two years in length, immediately following graduation from medical school, designed to give the medical school graduate real world experience in applying the theoretical concepts learned in class. 42 Adaptability to Change The only constant in the moder n world of work is change. New technology, global competition, and emerging world economies are changing the way employees work. Employees must commit to lifetime learning and continuous adaptation to changing environments. Discussion Two --Terminology During his first week on the job, Wes Douglas encountered many technical terms. He remarked that it was almost as if each department had a separate language. He recognized that effective communication would require him to learn new terminol ogy. One way to do this is to memorize certain Greek and Latin roots that serve as the basis for many medical terms. The list is provided on the next page for memorization. a- not, without, less acantho - thorn adeno - gland adip - fat albo - white algesi - pain ambly - dull angi - vessel anti - opposing aque - water arteri - artery audio - hearing aut - self bi- twice, double bacterio - bacteria brachi - arm carcin - cancer cardi - heart carpo - wrist cephal - the head che mo - chemistry crani - cranium cry - cold crypto - hidden cyan - blue cyst - bladder, cyst cyte - cell dactul - finger, toe deca - ten dent - tooth derm - skin duo - two dys - bad, difficult ect - outer, outside encephalo - brain epi - upon or following ergo - work erythro - red esthesio - sensation gastr - stomach galact - milk gingiv - gums gloss - tongue glycol - sugar gyn - woman hem - blood hepat - liver hist - tissue homeo - same hydro - water hyper - excessive hypo - beneath infra - below intro - within -ism disease -itis inflammatio n 43 kerat - cornea laryng - larynx -lepsy seizure lipo - fat lith - stone -logy study of macr - large melan - black morph - shape naso - nose necro - death nephr - kidney neur - nerve odont - tooth oma - tumor opthalmo - eye ortho - straight ossi - bone para - abnormal path o- disease ped - child, foot peri - around pharmaco - drugs -philia attraction phleb - vein phobia - fear phon - sound, speech photo - light -phylaxis protection plasma - plasma pleur - rib, side pnea - breath pod - foot poly - many pre - before pseud - false psych - min d ren - kidney rhin - nose -rrhagia discharge schizo - split scope - look sin - sinus somat - body spasmo - spasm spiro - breathing spleen - spleen stom - mouth super - in excess sub - beneath supra - above syn - together tachy - rapid tel - distant thorac - chest therm - heat thromb - clot thyro - thyroid tomy - cut toxi - toxin trache - trachea ultra - beyond uni - one uro - urine vas - vessel xanth - yellow zo - life 44 Discussion Questions 1. Edward Wycoff felt Hap Castleton and Wes Douglas would make a good team, as each would com plement the strengths and weaknesses of the other. What are the strengths and weaknesses of Hap and Wes? 2. Edward Wycoff related the story of several vice presidents of a large Fortune 500 company who were successful while holding important jobs within th e company, but lost their fortunes when they tried to go into business for themselves. Why did this happen ? What can a supervisor learn from this experience? 3. Why did Wes accept the offer to serve as interim administrator of Brannan Community Hospital? W hat did Wes Douglas have to win by accepting this offer, and what might he have to lose? Place yourself in the role of Wes Douglas. Would you accept the job? 4. It has often been said; How someone does something is as important as what he or she does. If y ou were chairperson of the board , would you have fired Roger Selman? Is there anything you would have done differently? 5. Assuming it was necessary to fire Roger Selm an, what do you think of Wycoff ’s timing? 6. What was the response of hospital employees to the appointment of Wes Douglas as administrator? What might the board have done to ease his transition? 7. So long as the board does the right thing, does it matter what the employees or the medical staff think of their actions? 8. Where does authori ty come from: a title, or credibility? 9. What will Wes Douglas have to do to build his credibility with the board , the medical staff, and the employees? 10. If an allied health employee has good technical skills, why is it important for him or her to have political savvy and good communication skills as well? 11. Birdie Bankhead, Hap Castleton’s secretary, believes Edward Wycoff may have hidden motives in selecting Wes Douglas as the new hospital administrator. What might these motives be? If Bankhead is correct, what can Wes Douglas do to protect himself? 12. Identify the root words of each of the following terms. From the roots, explain what you think the term might mean. Using a medical dictionary, write the definition : 45 cystitis gingivitis hematology histology hypodermic liposuction necrophobia necrosis ophthalmologist orthodontist pathology tracheoscopic 13 . Assume you are a healthcare practitioner talking to someone with no medical training about a loved one who has been admitted to the hospital. Translate the following into simple English the family can understand. a. I believe your 100 year -old aunt is necrophobic. b. The child was cyanotic at admission. c. Your father was suffering from apnea w hen he called us. d. Your son has severe gingivitis. Writing Exercise 14. Assume you were asked to fire Roger Selman. Prepare an outline of what you would say. Role -play the situation with another student in front of the class, showing courtesy and kind ness. Using the tools taught in Discussion One — Employability Skills develop a plan to explore a specific healthcare career. Consider (a) personal aptitudes , (b) education and training requirements , (c) pay and job opportunities, and (d) work environment. Cyanotic . Blue 46 Role -Playing Assignment 15. Select a team of six or more people to role -play the Board of Trustees of Brannan Community Hospital and the administrator before the class. Have the board develop a plan to save the hospi tal in the next 30 days. Address the following problems : (1) the hospital is not producing enough cash to pay its bills , (2) employee morale is at an all -time low , (3) the newspaper is running unfavorable editorials about the operation of the hospital , (4) the community is losing confidence in the quality of services provided by the hospital , and (5) there is talk of an initiative to close the hospital down. 47 4 ______________________________________________________________ Resolve and Regret hrough an open window in his small apartment, Wes listened to the noise from the street below. A freight truck was backing into an alley, and someone was shouting instructions to the driver in Spanish. The freight dock for the hotel next door was directly beneath his window. Wes rolled over and checked his alarm — 5:00 a.m. The weatherman had forecast stormy weather. Wes smelled the rain as it hit the dusty asphalt below. A gust of wind snatched a newspaper high in the air above the alley, and thunder rumbled in the distant mountains. Wes stumbled to his feet to shut the window. He returned to his bed. Sinking into the pillow, he took a deep breath, held it, and slowly released it . If I could ju st relax the muscles in my back. He eyed the medicine on the nightstand, tempted for a moment to swallow another painkiller. He reconsidered. They dulled his thinking, and he would need all of his mental resources to handle the problems of his second day. He gently straightened. It had been six months since the automobile accident, and this morning the pain in his lower back was as severe as the night they pulled him from his mangled automobile. He vaguely remembered being lowered onto an ambulance litter before passing out. Sometime later he drifted in consciousness. A paramedic had started an IV and was reading Wes’s vital signs over the radio to a nurse at the hospital. “Kathryn? . . . Where is Kathryn?” he whispered. “It’s going to be all right buddy ,” the paramedic answered. The paramedic lied — nothing would ever be right again. Friends told him time would soften the loss. Someday life would again have meaning. For now, the only relief was the distraction of hard work that left little time to think a bout anything else. Even so, his mind burned with her memory. Rarely an hour passed he didn’t think of Kathryn — her slender figure, twinkling green eyes — the impish smile that played at her mouth just before he kissed her. He closed his eyes, his mind cloudi ng with visions of the past. Paramedic . A person trained to provide emergency care. T 48 Unable to sleep, he sat up — carefully. He took a deep breath, and then nodded with firm resolve. It had been six m onths since he realized it was time to move on; find a new job, new friends. His answer was to relocate to a new part of the country. He picked Park City from a ski magazine. Erasing memories, however, was easier said than done. Often, in the slumber of t he early morning, he would return to the evening of the accident. In the recurring nightmare he would feel the play of the steering as the tires slipped on the wet pavement, the crushing impact of the crash; the blackness that blended the smells of burning rubber and gasoline mingled with pain, and the sound of the rain as it hit the dusty asphalt below.  Wes’s body was heavy with fatigue as he drove to work an hour later. To focus his thoughts, he reviewed the events of the previous day. At 1:00 PM he m et with Elizabeth Flannigan, the director of nursing . Flannigan was a fierce woman. She handled herself with the authority of a staff serge ant and rarely took direction from anyone. Focusing on the hospital’s financial problems, Wes quizzed her about nurs ing costs and discussed the possibility of cutting staff. He shouldn’t have done that — not during their introductory meeting. Flannigan and her staff were already paranoid. Alarmed, she ran to Dr. Emil Flagg, who confronted Wes in his office, pouncing on hi m with the fury of a Rocky Mountain thunderstorm. “Hell -bound financiers like Wycoff are destroying healthcare!” Flagg shouted, his enormous fists smashing a stack of financial reports on Wes’s desk. “Wycoff, the miserable rodent, thinks he can run this pl ace like a bank. This isn’t Wall Street, and our patients aren’t stocks and bonds !” The meeting lasted for an hour. Flagg was angry at insurance companies, paperwork, hospital administrators, and the other members of the board . Wes, in his eyes, was one wi th Wycoff. Wes assured him of his concern for the welfare of the employees. His voice was firm, however, when he reminded the doctor that the hospital was losing money and the board had hired him to do all in his power to save it from bankruptcy. The meet ing ended in a stalemate. As Wes’s car pulled into the parking lot, it occurred to him that accepting the job might have been a mistake. He didn’t’ have the background to run a hospital, and botching the job now would reflect negatively on his new CPA practice. He shook the thought off. Negative thinking never solved anything. Having committed himself, he would give the job his full effort.

Three hundred fifty employees depended on him. The hospital had served the residents of Park City for 65 y ears. It might fail — but not on his watch.  Bond . A type of borrowing instrument.

Hospitals can issue bonds to borrow money to pay for buildings and equipment. Director of N ursing . The chief nursing officer (CNO). This person has line responsibility for all nursing activities in the hospital. Stock . A share certifying the holder owns part of a corporation. 49 “Good morning, Mr. Douglas!” A noticeably more chipper Birdie Bankhead looked up from her computer and smiled brightly. The puffiness was gone from her eyes, and her voice was as sunny as the yellow pantsuit she wore. Wes smiled, grateful for the change . “You’re here early,” he said, nodding at the clock above her desk. “Had a ton of letters to finish before the phone started ringing,” she replied. She continued typing, and then looked up with a start. “That reminds me,” she said. “Hank Ulman, presiden t of the employee council , called me at home last night. He wants to meet with you — this morning at 10:00 a.m. at the Pipe Fitters Union Hall. I wrote the address down.” She reached for her purse. Retrieving a small notepad, she tore the message off and ha nded it to Wes. “920 South Brannan Avenue,” she said. “Small red building — second floor — just above the bakery.” Wes’s brows pulled into a scowl as he read the note. “Didn’t know we had a union.” “Technically, we don’t, but there’s been talk of one since Wyc off vetoed the budget,” she replied continuing to type. “He wanted Hap to cut salaries by 12%. Someone leaked the story to the newspaper. Caused quite a stir among the employees. That’s when the union talk began. Guess the issue is surfacing again,” she sn iffed, returning to her typing. “Hank Ulman,” Wes said, turning the note over in his hand. “One of our employees?” Birdie nodded. “Works in the maintenance department . Moonlights part -time as a mechanic for a flight service in Salt Lake City. He has a repu tation as a troublemaker. Ran once for city council — American Socialist Party ticket. Got seven votes. “Historically most of our employees ignored him. Four months ago, however, when Wycoff started getting involved in running the hospital, the employees ele cted him president of the employee council.” Wes frowned. “What do you mean by ‘ Wycoff started getting involved in running the hospital? ’?” “He manipulated the board into appointing him budget director,” Birdie replied. “Once he got control of the budget , he had control of the hospital.” “The Golden Rule,” Wes replied. “He who controls the gold makes the rules.” “Right,” Birdie replied. “Hap planned to take the responsibility back. He got Wycoff to agree to transfer the title to Del Cluff.” She sighed, “Of course, that was before the accident.” A dozen thoughts flashed across Wes’s face as he considered the issue. “Call Ulman,” he said finally “and tell him there’ll be no meeting, not with him, and not at the Union Hall. Then arrange a meeting with our empl oyees for 10 :30. Ask scheduling to pull in all on -call nurses for staffing coverage — I want as many of our full -time staff there as possible.” “Do you want supervisors at the meeting?” Birdie asked. “No, I’ll meet with them tomorrow.” Employee council . A committee of hospital employees, often elected, whose purpose is to represent the viewpoints and concerns of the employees to management. Maintenance departmen t. The hospital department responsible for maintaining buildings and equipment. On -call nurse . A nurse not assigned a specific time to work, but who agrees to be available to be called in on short notice . 50 Birdie scratched a note in her p lanner. Energized by completing his first official act, Wes was hungry. “Think I’ll catch breakfast,” he said brightly. “When I get back, let’s meet to plan the rest of the day.”  This was Wes’s first visit to the cafeteria. An arrow pointed to the bas ement. Taking the exit, he plowed down the stairs, shaking hands with two doctors on the landing. They asked for a meeting at his earliest convenience. “Schedule it with Birdie,” he replied cordially as he continued down the stairs. During Wes’s first inte rview, he found the lobby cold and uninviting. It reminded him of the lobby of a bus depot. He was pleasantly surprised, therefore, to find the cafeteria warm and cheerful. Nothing fancy — if anything, a little homespun — checkered red and white tablecloth and yellow walls. Canyon Elementary School had decorated the south wall with crayon drawings depicting brightly colored surgeons helped by chalk -white nurses. The aroma of eggs, bacon, and coffee drifted from a spotless kitchen. A radio was playing country m usic, and the room hummed with the pleasant chatter of 50 or so employees and visitors. Wes selected a tray and headed for the cafeteria line, confident few employees would recognize him as the new administrator. A good chance for a little reconnaissance. He grabbed a packet of silverware. An attorney friend once told him about a hospital malpractice case he handled. It involved a doctor who severed a carotid artery during surgery. For two days the attorney interviewed the surgeon and operating room perso nnel. Frustrated at his inability to crack the case, he sent two clerks to the hospital. Posing as visitors, they spent three days in the cafeteria, drinking coffee and eavesdropping on the conversations of hospital employees. “Get a group of nurses on bre ak and they’ll gossip,” he said. “Over coffee and rolls they gossiped about the case, the incompetence of the surgeon, and the medical executive committee’s long -standing inability to control or discipline the doctor being sued.” Having discovered more fro m cafeteria gossip than they would have learned in ten months of depositions , the attorneys approached hospital administration with their newfound evidence. They settled out of court for two million dollars. Wes paid for breakfast and took a table near the center of the cafeteria, not far from a group of housekeepers seated at a large round table. “Did ya hear they fired poor old Mister Selman?” a heavy woman in a blue housekeeping uniform said to her companions as she buttered a thick pancake. From a pictu re in the hospital newsletter, Wes recognized her as Betsy Flint, a long -term employee. Carotid artery . The artery that supplies the brain with blood. Deposition . Written testimony under oath. Malpractice . An act of professional negligence that injures a patient. Medical executive committee (MEC). The primary governing committee of the medical staff. The goal of the MEC is to conduct business in the hospital for and in behalf of the medical staff. 51 “It was Wycoff that got him,” replied a coworker, a frail woman with a thin rooster nose. “Now Mr. Castleton’s dead, Wycoff’s going to have his evil way with the hospital,” she blathered , pointing with her fork to a picture of the hospital on the wall. Her dark eyes turned bitter. “Doc Flagg said he’s been pushing staffing cuts for three months. He’ll have us all on unemployment if he gets his way.” The employees at her table nodded omino usly. “He don’t believe in unemployment insurance,” another housekeeper hooted. “He’ll have us on the street!” “Hap would never have stood for that,” Betsy said, her eyes widening with resentment. She took a hearty bite of her cheese omelet and leaned for ward conspiratorially. “Say, what’s this new administrator like?” “He’s a real dandy,” her companion replied, mirroring Betsy’s facial expression. “Flagg says he’ s Wycoff’s man — a guy from back E ast, a fancy finance fella. Doc says he doesn’t know nothin’ ‘ bout hospitals.” A flash of alarm exploded across Betsy’s stout face. “Good Jehosophat!” she said, rocking back in her cafeteria chair. Wes held his breath as the vintage chair — a survivor from the original hospital — groaned under her weight. It held, and a worker’s compensation injury was avoided. Wes’s eavesdropping was interrupted by the cafeteria intercom. “Mr. Douglas, line four,” the operator announced. Several employees scanned the cafeteria for a look at their new boss. When the interest died down, h e quietly made his way to the hall where he took the call. “Wes speaking,” he said. Birdie was on the other end. Her voice registered concern. “I have Mr. Wycoff on the line. Told him you were unavailable. He insisted I track you down,” she said. “Put him on,” Wes said softly . The phone clicked and Wycoff spoke. “Read the article in last night’s paper,” he began, his words coming in short staccato -like bursts . “I’ll be down shortly. Want to meet with the employee council. I’ve dealt with threats like this before,” his voice dripping with contempt. “Don’t know who they think they are, but I’ll nip this in the bud.” “Understand your concern, Mr. Wycoff,” Wes said politely, “but I’ll handle it.” “You can’t meet with them alone,  ” Wycoff said. Wes sensed the surprise in Wycoff’s voice. “That’s my intent,” Wes said calmly. It was important to establish policy early. “The board establishes policy and evaluates the administrator. The administrator runs the hospital. This is an operational issue — my turf.” “Don’t be a fool,” Wycoff said dropping the polite facade. “A good CEO uses the talents of his board .” “Not in operations he doesn’t.” CEO . An acronym for chief executive officer.

In a hospital, the CEO is the hospital administrator. Operations . Relating to the functioning or management of an organization. 52 Wycoff gasped at Wes’s boldness . “As chairperson of the finance committee, I’m going to meet with our supervisors on the financial crisis,” he announced with all the authority h e could command. Wes held his ground. “ As chairperson of the finance committee, you will meet only with the board . The board will set policy. I will relay that policy to employees,” he said. Wycoff sputtered. “I have several issues to discuss with the em ployees. The budget, our new organizational structure. . .” “Those are operational issues ,” Wes repeated firmly. Wycoff simmered silently. “I appreciate your concern,” Wes continued. “If I need your help, I’ll call.” Wes waved cheerfully at Dr. Flagg who stormed by without speaking. “Good -bye , Wes,” Wycoff said. Was that a farewell . . . or a threat? Wes wondered as the phone clicked dead.  It took a heroic effort by Housekeeping to prepare the cafeteria for a meeting on such s hort notice. The dietary department shut the breakfast line down promptly at 10 :00 a.m. — 30 minutes early as a team of housekeepers quickly descended on the department, removing tables, sweeping floors, and setting up chairs. Wes had one goal for the meetin g— prevent a walkout. The room filled quickly. Wes entered from the rear, and walked briskly to a portable podium at the front. He stood there as the room quieted. “I’m Wes Douglas, your new administrator,” he began. “I know my appointment as interim admi nistrator surprised many of you — none of you more than I.” A feeble attempt at humor — no one smiled . Wes noticed the audience was divided into three groups. A small cluster standing in the back exchanged guffaws with their ringleader — a stocky maintenance ma n with a barrel chest and large animated arms that swung out from his body like hams as he mimicked Wes. From an earlier description, Wes assumed the comedian was Hank Ulman — the self -appointed union steward . A second group, scattered throughout the audien ce, watched dispassionately, arms folded, faces skeptical. Convince us the board didn’t make a mistake , their expressions seemed to say. The third group — 10 or 12 people on the front row — were receptive. But being few in number, they seemed intimidated by ot hers in the audience. “I’d like to begin by explaining my management philosophy,” Wes continued. For the next ten minutes he discussed the goals he had set for the hospital, the most important of which was to keep the hospital from closing. “I’ve had my sa y,” he concluded. “Now, tell me your concerns.” Operational issues . Issues relating to the management or operation of a hospital. Union steward . An in - house union representative. 53 The room was silent. Finally, an employee from the business office raised her hand. “I have a complaint,” s he said. “The board never consults us; we don’t know what’s going on. There isn’t a single employee who has ever heard of you. Suddenly you’re the new boss.” The room hummed with agreement. “The newspaper editor knows more about what’s happening here than we do,” she continued. “Hap never told us about a financial crisis.” Her face twisted with skepticism. “How do we know it’s real?” “It’s real,” Wes replied. “Can you guarantee there’ll be no layoffs?” a nurse demanded. “No, but I’ll consult with your sup ervisors before cutting staff. There’ll be no secrets.” A lab technician raised his hand. “There’s a rumor you’re an accountant. I’ve got a complaint about the accounting d epartment . The employees get blamed for the hospital’s losses, but it’s not our faul t— accounting’s pricing policies are the problem. We’re doing some of our lab tests for less than the cost of reagents .” “Waste is another problem,” a nurse added. “Last week we threw away several hundred dollars of sterile products because they were outdat ed. This is a problem on all units.” Wes took notes. “Helpful input,” he said. Complaints continued for another 20 minutes. Finally, Wes summarized. “There was a time in my career when I blamed employees for poor quality. Experience has changed my mind . I realized the problem is poor management. Give me a few days to find out what is going on,” he said, “and we’ll hit the issues straight on.” His approach was working. Many employees smiled — a few applauded. It was time to discuss the threatened walkout. As the morale of the meeting improved, Hank Ulman’s hostility rose. Suddenly he left the room, taking with him two coworkers. Good riddance, Wes thought. Wes was in striking distance of his goal — or so he thought. He cleared his throat. “There’s one more iss ue I want to discuss,” he said as the employees quieted. “An article in the paper reported a threatened employee walkout. The hospital has problems, a walk out won’t solve them  ” A muffled explosion interrupted his words. A loud hissing noise followed as a stream of boiling water, red with rust, gushed through the opening under the boiler room door and swirled over the feet of the employees. A laundry worker in low cut shoes screamed in pain as she grabbed her ankles. A coworker grabbed her arm, but slipped on the wet floor and fell in the scalding water. Two men pulled them to their feet. Hank Ulman appeared in the doorway. Interestingly enough he was wearing hip boots. “A pipe to the boiler’s broken!” he shouted. “Everyone out!” Reagent . A substance used in the laboratory to detect or measure another substance. 54 The room exploded in commotion as the crowd convulsed to the front of the room, knocking over chairs in their efforts to escape the scalding flow.

An employee hit the crash bar to the emergency exit, setting off the alarm as workers pushed one another through the door and up the stairwell. Ulman had successfully ended the meeting.  Thirty minutes later, Wes met Hank Ulman in the hall. “Like I tol’ Hap, the boiler’s old — needs rep lacin’.” Ulman smiled, exposing a broken, chestnut colored tooth. “Gonna kill somebody someday.

The steam pipe came right off the wall. It’s good I was there. If I wasn’t, things might have turned out differently.” “I’m sure that’s true,” Wes replied flatl y. Discussion One --Assuming the Reins In this chapter, Wes Douglas assumes the reins of Brannan Community Hospital.

Many people will offer advice and help. Some will try to get the new administrator to take sides on issues they support or oppose. Here is some good counsel for anyone moving into a position of authority in a new organization : 1. Don’t commit yourself to a course of action on major issues until you understand what is going on. There will be people who will try to g et you to take a stand on an issue favoring their interests before you have all the facts. 2. Until you understand all the issues, listen more and talk less . Remember the famous quotation by Mark Twain : “It’s better to remain silent and be thought a fool, than to open one’s mouth and dispel all doubt.” Some people try to impress others with their knowledge by talking too much — that doesn't work. One advantage of quality listening is that you may actually learn something . When you finally do speak, you will do so with knowledge and authority. 3. Build rapport with your employees before taking major action. Some novice managers mistakenly believe the shortest distance between two poi nts is a straight line. Often the quickest course of action, especially when you are dealing with people, is not the best approach. Before you start giving orders, strive to understand each stakeholder’s point of view and to build consensus. Stakeholder . A person who has an interest in an organization, project or concept. 55 4. Remember how you do something is often as important as what you do. It is not enough to be sincere, you must be right. However, it is still not enough to be right, you must be effective. Many supervisors fail by doing the right thing , but in the wrong way. We no longer live in an economy where a title alone carries authority . A supervisor must gain the employees’ respect before he or she can lead. 5. Don’ t cri ticize your predecessor, even if he or she was incompetent. Your successor will have friends among your employees, whom you will alienate if you bad -mouth thei r former boss. Discussion Two — Teamwork Wes Douglas is seeking the help of his employees as he tries to save Brannan Community Hospital. He recognizes he can only solve the hospital’s problems with a team effort. Most work in the healthcare industry is do ne in teams. What is a team? It is a group working for a common goal. Hospitals use interdisciplinary teams — teams composed of people with different educational backgrounds — to work together in the care and treatment of hospital patients. Team members includ e the doctor who diagnoses the patient and develops a plan for care, registered nurses who supervise and direct hospital care, and non - licensed staff who perform duties assigned. Good team leaders delegate the right task, in the right circumstance, to the right person, who has the proper license and training. Effective team leaders direct, communicate, supervise, and give feedback on employee performance. Many schools do a poor job of teaching teamwor k. Most students compete for grades with assignments individually completed. Usually there are penalties for working together on an assignment. This is unfortunate, as the ability to work with others is one of the most important characteristics employers l ook for in new employees. What characterizes a successful team? Researchers have identified seven elements:  Leadership  Common goals  An understanding of the role of each team member  Att ention to activities that build team spirit  An ability to meet the needs of each person on the team  Trust Interdiscipli nary team . A group of people with different educational backgrounds who come together for a specific project. 56  Good communication  Respect for facts Leadersh ip Although there are many effective management styles, successful leaders share several characteristics. Successful leaders:  Understand the goal to be reached  Accept resp onsibility  Seek input from all team members  Break complex goals into tasks that they can delegate  Possess the ability to inspire and manage people  Understand the importance of human resources  Have good listening skills  Understand and respect diversity  Supe rvise and give feedback Good team leaders are service oriented. The greatest leader is one who serves. Common Goals Successful teams have mutual goals or objectives and share a sense of urgency in completing those goals. A nursing team’s goal is to treat patients. An Understanding of the Role of Each Team Member Members of successful teams understand the responsibilities of each player. They know what they can expect from each member and realize that everyone contributes to the team effort. Attention to Ac tivities that Build Team Spirit Successful teams recognize how important team spirit is and devote time and resources to building that spirit. Team building activities include:  Periodic meetings to set goals and measure progress  Newsletters Human resources . The personnel department. 57  Certificates of appreciation  Thank you cards  On the spot rewards (for example, movie tickets for nurses asked to work a double shift)  Parties and other fun activities to celebrate accomp lishments Successful teams celebrate cooperative effor t— they will not intentionally allow one member to benefit at the expense of another. Ability to Meet the Needs of Team Players Successful teams meet the needs of each team mem ber. Team members need:  A sense of accomplishment  Control over their e nvironment  Freedom of thought, action, and growth  Recognition and prestige  A sense of belonging  Security Trust Without trust, team members are unwilling to rely on the experience, judgment, or personal commitment of others. Trust involves:  Respect for the talents and roles of each team member  Acceptance of dif ferent backgrounds, opinions, and contributions  Willingness to take the risk of interdependence  Problem solving , rather than b argaining  Willingness to allow others to make mistakes o Mistakes are often stepping -stones to success. There is no such thing as innovation without error. When employees make mistakes, the emphasis should be on learning, not punishment. o This is not to say teams should allow mistakes to occur through carelessness or a lack of planning. 58 Good Communication In healthcare, a failure to communicate can lead to the injury or death of a patient. Communication is an important part of teamwork. Communication can be verbal or nonverbal. Nonverbal communication improves and supports verbal communication , and includes body language, facial expressions, and ge stures. Good communication has four ingr edients:  The sender  The message  The receiver  Feedback When communicating with patients :  Consider the listener’s education and underst anding.  Keep it simple. Avoid using technical language the listener will not understand.  If a patient spea ks another language, get an interpreter.  If the patient is hearing impaired, speak loudly and clearly, but never shout.  Reinforce your message with nonverbal communication.  If the patient is confused, simplify your message. Use short, clear sentences  Face the patient and d use proper eye contact.  Seek feedback to assure the listener understands what has been said o Ask the patient if he or she understands the message. o More important, have the patient repeat what has been said.  Always show courtesy and respect . Respect for Facts Successful teams have an ability to colle ct and analyze data. They rely on facts, not opinion. 59 Discussion Questions 1. The first meeting of Wes Douglas with Elizabeth Flanni gan, director of nursing, didn’t go well. If you were the new administrator, explain how you might have established rapport with your new nursing director before exploring a controversial topic such as cost reduction. 2. How can plan ning for an important meeting with a supervisor, coworker, or subordinate raise your cha nce of success? What issues might you want to include in such a planning session? 3. Emil Flagg, the representative of the medical staff on the board of Trustees , is an important stakeholder in the operation of the hospital. What would have been your approach in defusing Dr. Flagg’s anger during his first meeting with the new hospital administrator? 4. From the conve rsations of hospital employees Wes Douglas monitored in the hospital cafeteria, it is obvious the employees have a negative impression of their new administrator. List possible reasons for this. If you were interim administrator, how would you address this problem? 5. Sometimes, people jump before they think. Wes Douglas, for example, is having second thoughts about accepting the job of administration. Given that he has accepted the job, what do you think is his best course of action?

Should he bail out, wa lking away from the commitments he has made to the board , or hang in there and try to salvage the situation? 6. Hank Ulman, president of the employee council, thinks he sees a vacuum in leadership — one he is eager to fill. What are his motives? Does he hav e the best interests of the hospital at heart? List several alternative courses of action Wes Douglas might take in neutralizing Ulman's efforts. List the advantages and disadvantages of each course of action, telling what you would do if you were the inte rim administrator. 7. According to Wes Douglas, what is the role of the board, and what is the role of the hospital administrator? 8. Wes Douglas canceled the meeting with Hank Ulman at the Union Hall.

Why did he take this course of action? How would you h andle the situation? 9. During a telephone conversation between Wes and Edward Wycoff, Wycoff expressed his wish to involve himself in solving the hospital’s operating problems. What are the advantages and disadvantages of having a board member involved in daily operations? 10. Why are elevators and hospital cafeterias a good place for reconnaissance by attorneys who have malpractice suits against the hospital? What ramificat ions does this hav e for patient privacy? Is there a lesson for hospital employees? 60 11. What do employees think of Edward Wycoff, chairperson of the finance committee? Why do they think Wes Douglas is in Wycoff’ s camp? Should Wes D ouglas distance himself from Wycoff? 12. If an employee believes she has two bosses, is there a possibility she will play the one agains t the other? 13. By telling Wycoff to stay out of operations, Wes offended one of his few alli es on the board . Was this the right action to take? 14. What do you believe Wes Douglas’s purpose was in meeting with the employees this early in his administration? What message would you have sent to your employees in your first meeting? 15. List five ch aracteristics of successful teams. 16. List four ingredients of good communication. 61 5 ______________________________________________________________ Amy he following morning was filled with meetings with c ommunity leaders concerned about the future of the h ospital and the impact a closure might have on the local economy. It was noon when Wes returned to the hospital. Birdie Bankhead was leaving for lunch w hen he met her in the employee parking lot. “There are several messages on your desk,” she said, fishing in her purse for her keys. Her eyes widened. “That reminds me,” she said. “Hap’s daughter Amy came by this morning to clean out his office. She’s still there. You’ll enjoy meeting her.” Wes nodded and headed for the employee entrance. By now, everyone recognized him as the new administrator. Just navigating from the parking lot to administration was a difficult chore, as doctors, supervisors, and employ ees collared him to voice complaints and give advice. It took 20 minutes from the time he entered the building to the time he arrived at administration . By the time he reached his office, his arms were full of three -ring binders with past minutes of the credentials committee the secretary of the medical staff asked him to review and sign. Nudging the door closed, he leaned against it and caught his breath. He dropped the binders on Birdie’s desk. With the interruptions, he had forgotten about Amy Castleton . He was surprised when, through the door of Hap’s old office, he saw her reading from a stack of papers on the massive walnut desk. Her head was turned gently to one side, exposing a slender white neck. She had long, amber hair that glowed softly in the s unlight that poured through the French doors leading to the patio. Mute, he stared at her as she read from a letter she picked up from Hap’s desk. She looked up, startled. “Hi,” he said, “I’m Wes Douglas.” Pursing her lips, she studied him for a moment — then her eyes lit with recognition. “Wes Douglas — of course . . . Father’s new financial consultant,” she hesitated, “and now his replacement.” She smiled sadly and held out her hand. Wes gently shook it as he sat in the chair next to hers. Credentials committee . The medical staff committee that reviews the ap plication of physicians to perform specific procedures in the hospital and recommends to the hospital Board of Trustees that the physician be given or denied these privileges. T 62 “Dad was pleased with your decision to consult with the hospital,” she said. “I’m sorry you didn’t have more time to work together.” “I’m sorry too,” he said gently. A shadow crossed Amy’s face and her brown eyes filled with tears. Looking down at the letter she was holdin g, she bit softly on her lower lip. It was the first time he’d felt clumsy around a girl since he fell in love with Carol Reimschussel in the sixth grade. As he stared into her eyes, an unfamiliar intensity overcame him. It took a moment for him to realiz e he was still holding — squeezing actually — her hand. She looked at their hands and then into his face. A questioning look stole across her eyes. Blushing, he released her hand.

Anxious to start anew, he pointed to a painting on the wall above the credenza. “Interesting picture,” he said. “I noticed it when I first met your father — is it yours?” Color touched her cheeks. She smiled and nodded. “I painted it when I was five -years -old,” she stated. “Dad framed it and hung it in his office — I was so proud.” Her e yes, soft and sentimental, slowly surveyed the room. “Some of my happiest hours were spent here on Saturday mornings,” she said. “Mom was taking a class at the university, and Dad would bring me with him while he opened the mail and caught up on correspond ence. I’d read, or draw, or paint.” The picture, painted with acrylics, was six by eight inches and framed in walnut to match the paneling of the office. A drawing of a large man holding three balloons dominated the picture. At his side was a small girl ho lding a flower. A huge tree, the sun, flowers, chipmunks, and stop signs, in all their profusion of color, filled the remaining white space. “Those were all the things I knew how to draw at that age,” she explained, an impish smile playing at the corners o f her mouth. “Dad wasn’t given much to worrying,” she continued, “but during the last few weeks of his life things changed.” Her eyes narrowed as she searched for the right words. “He acted as though something was wrong, but he wouldn’t talk about it. Six weeks before the accident, he took out a life insurance policy. “People sometimes have premonitions,” Wes said. “We hoped the fishing trip would restore his enthusiasm,” Amy said sadly. “He seemed so tired — ” Neither spoke as she examined the belongings sh e had removed from his desk. “I was finishing when you came in,” she continued. “In a few more minutes I’ll have all of Dad’s belongings, but I can finish later if you need the office.” “Take your time,” he said. “I’ve other errands to run.” 63 Amy’s eyes softened as sh e shook her head and smiled. “I hope you will visit us,” she said. “I know Mother would enjoy meeting you.” He nodded and turned to leave. As he did, her hand gently brushed his. As he walked to the parking lot, he wondered if there was something else she wanted to tell him.  Wes Douglas had settled into a routine. Often, in the evenings he would visit the nursing stations. It was a good chance to meet employees and talk to patients. Both were a good source of suggestions. One patient asked for a clock in the room so she would know when to take her medications. Wes got her one. If he ever built a hospital, there would be a clock in every room. The food carts were noisy early in the morning when most patients were trying to sleep. He talked to the dieta ry director about training the transportation aides to be quieter. “Could you invent a modest hospital gown?” a young executive asked. It was a good idea. From his own experience as a patient, Wes remembered having to hold his gown together to keep from ex posing his backside when he walked. “I was cold when they wheeled me to radiology for tests,” a patient reported. From then on, patients were gowned, and covered with cotton blankets when transported through the halls. “Ever take a ride through the hospit al on a gurney?” a patient asked. “You’ll see things people don’t see standing up.” It triggered Wes’s curiosity. He tried it. The next morning he directed Housekeeping to wash the ceilings and remove the cobwebs. A sociologist from the University of Wyom ing was admitted after a hiking accident. “Your hospital has a way of dehumanizing people ,” the professor said, “of stripping them of their personal identity. You replace their clothes with a generic gown. Anything that differen tiates them from others, including jewelry, is impounded. “It’s insulting not to be called by your name. I’m not the gallbladder in room 247 , I’m Robert Hansen!” Wes took notes. If he survived the financial crisis, he would find ways to humanize the hospi tal experience. One evening Wes was visiting patients on the second and third floors. As he exited the elevator, he bumped into a ten -year old boy in a wheelchair. The kid wasn’t seriously injured, but obviously had done something bizarre.

Both legs were i n casts, his hands were bandaged, his hair was singed, and his eyelashes were missing. Wes smiled. He remembered how easy it was to get in trouble at age ten. One of these days, he’d have to apologize for the anxiety he and his younger brother put their p arents through. Radiology . A branch of science that uses radiant source energy (especially x -rays) in the diagnosis and treatment of disease. Sociologist . One who specializes in the history and function of human society. 64 “What did you do ?” he asked curiously. “Climbed a power pole to catch a bird,” the boy replied. His face sobered. “When I touched the wire,” he said slowly, “I stayed in the air . . .

but my body dropped . I watched it fall . . .” His singed eyebrows rose in astonishment. “When it hit the fence,” he said, “I went back into it.” The boy looked as though he expected Wes to answer a question he himself wasn’t old enough to put into words. Wes was silent as h e studied the boy quietly, not exactly sure how to respond. Finally, he nodded. “Well,” he said, his voice soft but upbeat, “We’re glad you’re back!” Down the hall, in room 352, was a 16 year -old boy with spiked green hair, a tattoo, and three body pierci ngs. Since his admission, the patient oscillated between ominous silence and violent rage. A drug user, he was admitted the previous evening with his second case of hepatitis — a dirty syringe. “Keep this up,” his doctor said, “and your next visit will be t o the morgue.” The boy cursed loudly , his face twisted with rage. His doctor ordered a psychiatric consult. Wes visited only once. The young man blew him into the hallway with a volley of profanity. Wes continued down the hall, hopeful someone would help h im before it was too late. In the next room, in a circle electric bed , was a young police officer from Heber, Utah. His name was Don Hemphill. Initially, there was a problem with his insurance. The hospital was at fault. Wes resolved it and apologized. Sin ce then, Wes visited whenever he was on the floor, and they had become friends. Hemphill was 32 years of age and had a wife and two little girls, one four and one six. They visited each evening. Tonight they were there in bright red dresses that matched t he valentines they were giving their father — never mind that it was October. “God has been good to me,” Don told Wes earlier that evening. “I’m going to beat this you know.” Wes admired his optimism, but Don was wrong. A few minutes later the doctor told Co nnie Hemphill that Don had an ependymoma — a cancer of the spinal cord. He would be dead by December. Connie returned home and retrieved the love notes his daughters had made but were saving for Valentine’s Day — hence, the valentines in October. Wes paused o utside the doorway, not wanting to interrupt. His expression was still and serious. I don’t understand. Down the hall, we have a teenager who has given himself hepatitis — twice. He’s throwing his life away, says he doesn’t care if he lives — but he will. And here, we have a young father who wants so desperately to live — but won’t. Wes continued down the hall. As a hospital administrator, he was often confronted with issues for which his business degree provided little, if any preparation. Circle electric bed . A bed for patients who cannot or should not move. A circle electric bed looks like a Ferris wheel. The patient is strapped in the position of one of the spokes, enabling him or her to be rot ated from time to time to remove pressure from parts of the body that may develop sores called decubitus ulcers.

Decubitus ulcers are painful and difficult to cure. Ependymoma . Cancer of the spinal cord. Hepatitis . Inf lammation of the liver, often caused by infection. 65 Discussion One --Patie nts’ Bill of Rights Wes Douglas is concerned with the way patients are treated by doctors, nurses, and allied healthcare workers. In this chapter, he visits with a sociologist who accuses the hospital o f dehumanizing patients. In their desire to apply the best scientific techniques possible in treating disease, healthcare workers sometimes ignore the rights and feelings of patients. In response to this criticism, Wes directs the Administrative Council to develop a patient bill of rights for Brannan Community Hospital. Wes Douglas appoints Elizabeth Flannigan as chairwoman of the committee and she submits the following draft. Brannan Community Hospital — Patients’ Bill of Rights Brannan Community Hospital sh all have a h ospital ethics committee, the purpose of which shall be education, policy review and development, and case review. The staff of Brannan Community Hospital recognizes patients have the following rights: 1. To know the nam e and professional status of all people providing healthcare. 2. To know the name of their attending doctor. 3. To receive complete information on their diagnosis and treatment. 4. To be given the prognosis for their illness. 5. To review all of the information in the ir medical record . 6. To have every procedu re, treatment, or drug therapy explained to them in language they can understand. 7. To know the possible ri sks, benefits, and costs of every procedure, treatment, or drug therapy. 8. To accept or refus e treatment. 9. To prepare, in advance, treatment directives and to expect these will be honored. Administrative coun cil. Department heads that meet regularly to coordinate activities of the hospital. Medical record . A record created on admission that records the treatment provided during the patient’s hospital stay. 66 10. To appoint a person to make decisions about their care, if they become mentally disabled. 11. To have personal privacy . 12. To receive compassionate care and proper management of pain. 13. To seek a second opinion. 14. To ask that the Hospital Ethics Committee review their c ase. Discussion Two — Healthcare Ethics Definitions  Ethics is the study of the principles of right and wrong.  Morals are personal standards of right and wrong.  Laws are rules that enforce behavior. Just because something is legal, or cannot be proven illegal, does not always mean it is moral. Ethical conduct is dependent on personal morality. Importance of He althcare Ethics The field of ethics concerns itself with t he way that individuals behave, the manner in which they exercise their power , and the impact it has on their fellow human beings. A subcategory is biomedical ethics, which has received increasing attention in recent years. The reasons for this include:  New technologies that have prolonged life and changed the definition of death.  A society that increasingly looks to lawsuits as a way of resolving unsatisfactory medical outcomes.  An increased sensitivity to individual rights.  A willingness of society to examine controversial issues , such as abortion and euthanasia. A Framework for Ethical Thought How should one approach ethical issues? There are two common schools of thought.  Deontological School : The Greek Word “deon ” means “duty.” This school studies moral obligations. Followers believe in the existence of Ethics . The study of the principles of ri ght and wrong. Law. A minimal rule of conduct enforceable by a controlling authority, usually a governmental entity. Morals. Personal standards of right and wrong. Standard. A performance goal. 67 good and evil and that individuals have an obligation to do good for other people.  Te leological School : The Greek Word telos means “end.” This school believes the end is all that matters. The teleological school focuses on that which provides the most positive result for the greatest number of people. Th e Teleological school believes : “The end justifies the means.” Rules for the Heal thcare Ethicist Since an examination of the strengths and weaknesses of deontological and teleologica l arguments is beyond the scope of this book, we will use another model, one that focuses on seven principles acc epted by most ethicists as being useful in resolving biomedical ethical issues. These principles are:  Free agency  Equality  Kindness  The obligation to do good  The obligation to do no harm  Honesty  Legality Free Agency : A patient has a right to make decisions about his or her own body without outside control. Difficult Questions Raised: 1. In making decisions about one's own body, does one have the duty to consider the impact those decisions might have on others (i.e. chil dren, members of society who sometimes must pick up the bill, and so on)?

For example, does a parent who plans to commit suicide have a moral duty to his or her loved ones? 2. If society is responsible for treating individuals with preventable illnesses, wha t (if any) responsibility does a person have to avoid unhealthy habits and practices? 68 Equality : The healthcare system has a duty to treat all patients fairly. Difficult Questions Raised: 1. Is equality possible? Resources are scarce. How do you treat 100 patients needing a heart transplant equitably, when there are only 50 hearts available? 2. Should patients who cause their illness through poor lifestyles have the same access to transplants and other expensive p rocedures as those who have tried to take care of their health? Kindness : A patient has a right to expect that a healthcare worker will be merciful, kind, and charitable. Difficult Questions Raised: 1. What is kindness? Is there a universal definition? If not, whose definition do we use? 2. Is it kind to inflict pain to raise the likelihood a disease will be cured? 3. Is it kind to increase the length of life when the quality of that life is low? 4. Is euthanasia against one’ s will ever kind? Obligation to d o Good for Others : Health -care workers are obligated to take the action that will result in the best outcome for the patient. Difficult Questions Raised: 1. Is t here a universal definition of “the best outcome ?” If not, whose definition should be used? 2. If death is viewed by one as a supreme evil, then is saving life at any cost (including suffering and pain) an ultimate good? 3. What if the patient does not want to live? How does the duty of the health pro fessional to “do good” relate with the patient’ s right to free agency? 69 Obligation to do no harm : The first obligation of a healthcare practitioner is to avoid injury to his or her patient. Difficult Questions Raised: 1. What about experimental procedures that may not help, and may harm the patient? Is it okay to risk a patient’s life to develop a surgical technique that may save patients in the future? Honesty : A healthcare worker should be honest. Difficult Questions Raised: 1. Is it always good to tell the truth? What if telling the truth in the opinion of the family will reduce the quality of life of the remaining days of the patient? 2. Should you tell the truth if it harms or destroys se lf-esteem? 3. Do we always know th e truth? One philosopher said: “ If it comes to being truthful or kind, I choose to be kind, I know wh at kindness is.” Do you agree or disagree with that statement? Legality : Are the actions of the providers consiste nt with state and federal laws? Discussion Questions 1. Some patients feel admission to a hospital is a dehumanizing experience.

Explain how hospitals strip patients of their personal identity. Can you think of examples not cited in the textbook/novel? Why is it important to treat patients as individuals, instead of numbers or diagnoses? 2. Traditionally, patients were not allowed to review the information in their medical records. Do you think this was for the benefit of the patient or the healthcare practitioner? Why do you think this policy was changed in the Patients’ Bill of Rights? 3. Use a search engine on the Internet to find the American Hospital Association’s Patients’ Bill of Rights. Compare this to t he Patients’ Bill of Rights as written by the Administrative Council. Can you think of additional rights you might add to the list submitted by Elizabeth Flannigan? 70 4. Write a memo to a hospital supervisor about your concern that your hospital is not giv ing enough attention to preserving the dignity of their patients. Propose several programs the supervisor can adopt to create less dehumanizing hospital care? 5. Like it or not, sooner or later there will be rationing of hea lthcare resources. Otherwise, the United States will eventually spend 100% of its income on healthcare. A difficult question is how these resources will be rationed. For example: Assuming two people need a transplant, and there is only one organ available, what should be the rationing criteria? Possible criteria include: a. How Important is the Person to Society ? The problem with this approach is deciding what we mean by “important.” Who is more important, a 65 -year old politician, or a 24 -year -old mother of four? b. Ability to Pay : Do the rich have a greater right to life than the poor? c. Age : Should an organ be given to the person with the most years left to live? d. Probability of the Best Outcome : If one person has a 50% of living with the new organ, a nd the other a 75% chance, should the second person be given the organ? e. Personal Responsibility for the Illness : Two people need a lung transplant. One person developed cancer from smoking, the other developed cancer from a genetic defect. Should person al accountability be considered ? f. Some Other Rationing Criteria Required : Assume you have been appointed Secretary of Health and Human Resources and have been asked to come up with criteria for the allocati on of scarce healthcare resources. Write a three - to five -paragraph statement defining criteria you think would be fair. Remember, in the real world there is sometimes no “right answer.” What this book tries to do is help you recognize the difficult decisi ons healthcare policy makers face, and provide experience in approaching difficult issues. The purpose of this question is to get you to think. 6. Form the class into groups and , using the following form as a basis for discussion , review each of the actual case studies presented at the end of this chapter . Use the guidelines presented, and others you may think of to determine what the ethical issue is, who the stakeholders are, and whether the concerned parties acted ethically. Have a representative from ea ch gr oup report on their conclusions. 71 Guidelines for Answering Bioethical Questions Free Agency Self -determination and freedom. The right of a rational person to self -rule and to generate personal dec isions independently. Questions to Ask: Answers from Group Discussion: 1. Is the patient mentally and legally competent? 2. Is there any evidence of incapacity? 3. If competent, what is the patient stating about preference for treatment? 4. If disa bled, who is the patient’s proper representative? 5. Is the patient's representative using a suitable model for decision -making? 6. Has the patient expressed prior preferences through advanced directives? 7. Is the patient's right to choose respected ? 8. Has sufficient time been given for the patient to discuss and evaluate outcomes? Other questions the group may raise: 9. 10. 11. 12. Equality The health care system must treat all patients equally. Questions to Ask: Ans wers from Group Discussion: 1. Are there biases that might prejudice the provider from giving a proper evaluation of the patient's quality of life? 2. Are their family issues that might influence treatment decisions (exhausting the estate through medica l bills)? 3. Are there other financial factors that might influence a proper evaluation of the patient's quality 72 of life? 4. Are there conflicts of interest with the provider (doctor or hospital payment for example) that might influence the decision to withdraw life support? Other questions the group may raise: 5. 6. 7. Kindness/Duty to do Good Deeds of mercy, kindness, charity, and consideration for the welfare of other people. Questions to Ask: Answers from Group Discussion: 1. What are t he prospects with or without treatment for a return to a normal life? 2. What physical, mental, and social shortfalls is the patient likely to experience if the treatment succeeds? 3. Are providers or others influencing decisions about treatment trying to see the situation through the patient's eyes? 4. Is the provider giving the care that provides the most benefit to the patient? Other questions the group may raise: 5. 6. 7. 8. 9. Obligation to do no Harm Don't hurt the patient―the over riding principle for everyone that undertakes the treatment of patients Questions to Ask: Answers from Group Discussion: 1. Is there a plan with a justifiable reason to forgo treatment? 2. If the treatment is experimental, has the patient been forewarn ed of the possible adverse effects? 3. Are there plans for comfort and the relief of pain? 73 Other questions the group may raise: 4. 5. 6. Honesty Is the health -care worker telling the truth? Questions to Ask: Answers from Group Discussion: 1. Has the patient been given a clear understanding of his or her diagnosis? 2. Is the patient aware of the different treatment options? 3. Does the patient know the potential benefits and dangers of each treatment option? 4. Is there any reason the pat ient should not be told the truth about his or her condition? Other questions the group may raise: 5. 6. Legality Are the actions of the health -care provider consistent with state and federal laws? Questions to Ask: Answers from Group Discussion: 1. Has the patient left a living will or health -care proxy? 2. If there is a living will, do the instructions clearly cover treatments the patient does not wish to receive, such as his or her wish not to receive CPR, respiratory or chemotherapy? Are the se directives being followed? 3. Does the living will describe conditions (i.e.

terminal illness, permanent coma) for which the patient would refuse treatment or interventions. Are these directives being followed? Other questions the group may raise: 4. 5. 74 Bioethical Case Studies Healthcare Ethics Case Studies: Use the model given in discussing the ethical issues involved i n e ach of the following situations, and then present your conclusions to the class. Case One : A 47 -year -old American Indian under treatment for depression attempted suicide by placing a shotgun under his chin and pulling the trigger. The blast blew off h is chin, nose, eyes, and left him deaf. An ambulance was called and the paramedics provided lifesaving services. He was life -flighted to the nearest major medical center where heroic measures were taken which saved his life. He will be institutionalized fo r the rest of his life. Excluding legal issues, which may not always correlate with ethical issues, who were the stakeholder s and what are the ethical issues? Case Two : An 86 -year -old independent male was involved in an automobile accident that fracture d the vertebrae of his neck. He suffers from severe neck pain but the doctors concluded that repairing the injury would cost him his life. A C -collar was placed on him, which he must wear for the rest of his life. He complains it is painful to wear. He has a tracheotomy, is vent dependent, is fed through a gastric tube, and (before the tracheotomy ) had expressed a wish to die. His daughter, however, has power of attorney. Nurses report that he can no longer talk , but that when they hold his hand he cries. H e has a two -point restraint because he tries to remove the ventilator when his hands are free. Who were the stakeholders and what are the ethical issues? Case Three : An individual with a similar situation to that portrayed in Case T wo has been involunta rily ventilated. To conform to her wish not to have a tracheotomy , nurses have placed a mask on her face that forces high -pressure air into her lungs. The designers of the device admit that it is uncomfortable and should be used for short periods only. To conform to her previous request that she not have a gastric tube put into her body, which would have been relatively painless, she now has an NG nasogastric tube, which is considerably less comfortable. As she wishes to die, which is against the wish of he r daughter who has her power of attorney, she has been placed under two -point restraint because she tries to remove her mask, gastric tube , and so on. Before entering the hospital , the patient w as taking Vicodin for nerve pain, and , on occasion , had taken Neurotin for arthritis. As her pain increased , the doctors ordered morphine. Her daughter recently instructed the nurses she didn't want her mother on pain m edication as she “wanted her to be mentally alert” when she visited her. She requested that they give her no pain medication unless she was present to give permission. A nurse who felt the situation was a f orm of torture confronted her. “ You mean that if y our mother is in terrible pain you don't want us to give her pain Ventilator . A mechanical device for artificial breathing. Narcotic . A drug, natural or synthetic, with effects similar to those of opium. 75 medication unless you are present to give permission?” the nurse asked. The daughter reconsidered fo r a moment and then said: “ I see your point, disconti nue pain medication completely.” The nurses report the woman’s body is shutting down and she wishes to die. She has been put under restraint as she tries to remove the life sustaining equipment when not restrained. Who are the stakeholders and what are the ethical issues? Case Four : A 39 -ye ar -old woman in the Midwest allowed her 17 -year -old daughter to use her car , even though the daughter had been drinking. The 17 -year old was involved in a severe automobile accident. Her 14 -year -old sister, who was in the automobile with her, suffered seve re brain damage. The mother was advised by an attorney that , if the 14 -year -old died , the 17 -year -old daughter and perhaps the mother would face charges of manslaughter. When the 14 -year -old daughter's system started shutting down , she was placed (at the d irection of her mother) on dialysis, given a pacemaker, and placed on a vent. She soon became 100% vent dependent.

Nurses report that , before her death , the young girl spent several years in severe pain. Who were the stakeholders and what are the ethical i ssues? Case Five : Nurses at an Alabama Hospital were instructed to give the charge nurse discontinued narcotics with a sign -out sheet. Over a period of time, several nurses noticed the documentation was disappearing. There was some doubt as to whether th e narcotics had actually been destroyed . The charge nurse’s supervisor, a close friend, later reported that she fired her but did not note she had confessed to taking the narcotics as she “ didn't want to destroy her career and her life.” The charge nurse found a new job in an acute care hospital in an adjoining state. She worked in endoscopy where it was common to give IV Demerol routinely. Patients within the unit often complained that they were not receiving satisfactory pain relief. The nurse eventuall y overdosed and went into full cardiac arrest. She recovered and was subsequently arrested and now faces the possibility of a prison term and a $10,000 fine. Who are the stakeholders, and what are the ethical issues? Case Six : A 23 -year -old woman overdos ed on heroin. Her doctors reported that she was brain -dead and recommended taking her off the ventilator. Her mother believes that God will provide a miracle and the young woman will recover, marry , and have children and , therefore , has requested that ever ything be done to resuscitate her daughter in the event of cardiac arrest . The cost to Medicaid is over $30,000 a month. Who are the stakeholders and what are the ethical issues? 76 Case Seven : A child under 18 years of age is brought in fo r a tonsillectomy. The child's parents have religious beliefs that preclude an individual from receiving blood. They tell the hospital that if the child bleeds there is to be no blood transfusion. Who are the stakeholders, and what are the ethical issues? Case Eight : A 37 -year -old man is brought in for a tonsillectomy. He has religious beliefs that preclude him from receiving blood. He directs the hospital in writing that if there is bleeding, blood is not to be administered. How is this situation differ ent from that reviewed above? Case Nine : A 21 -year -old woman is 20 weeks pregnant and in need of radiation therapy b ecause of a frontal brain tumor (anaplastic astrocytoma ). The medical ethics committee found that: “The mother’s life is in a medical cri sis with such an aggressive tumor. The mother is critical to the life of the fetus.” The committee recommended radiation treatment that will have the least effect on the fetus. The mother has refused radiation for fear it will harm the baby. Who are the stakeholders, and what are the ethical issues? Case Ten : A 25 -year old woman had in vitro fertilization. She became pregnant , but all six embryos attached. She was encouraged to have doctors selectively remove some of the embryos to raise the chances of li fe without disability to the other infants and possible death to the mother. The mother’s religious beliefs discourage her from abortion and she continues with the pregnancy.

Who are the stakeholders, and what are the ethical issues? 77 Case Eleven : A chief nursing officer (CNO) is approached by the director of maintenance who is aware that she and her husband have been shopping for a contractor for a new patio at their home. The hospital has just poured a new sidewalk and h as excess concrete. The director of maintenance offers to send his personnel to her home to pour the patio free. “There will be no additional cost to the hospital , as the workers are already on payroll,” the director of maintenance assures. Who are the sta keholders, and what are the ethical issues? Case Twelve : A CNO sits on the hospital equipment committee. She was instrumental in selecting Brand X heart monitors, an expensive capital acquisition. After the order has been placed, the seller offered to g ive her an expensive gift as a way of saying thanks for her influence. The gift was not discussed before the decision of the equipment committee. Who are the stakeholders, what are the ethical issues? Case Thirteen : A doctor had a member of his church co ngregation die, an individual held by high esteem in the community. The individual died of AIDS , and had never received a blood transfusion. To protect his friend’s reputation, the doctor changed the admitting diagnosis in the medical records after the death. Who are the stakeholders, and what are the ethical issues? Case Fourteen : A 58 -year -old woman was admitted to the hospital with a terminal injury. She had never applied for Medicare , although she qualified , because her f amily had limited resources. The business office manager was finally able to get a verbal commitment that all costs would be covered retrospectively as of 2 p.m . At 1 p.m. she died and it appears, therefore, there will be no payment. A nurse suggests they change the hour of death to allow for payment. Who are the stakeholders and what are the ethical issues? Case Fifteen : A baby formula seller offers to provide hospital administration free formula for babies within their family. Pharmaceutical reps offe r the same program. Doctors are offered expensive vacations to exotic locations by pharmaceutical companies under the guise of educational conferences. Who are the stakeholders and what are the ethical issues? Case Sixteen : A small rural hospital is on the verge of bankruptcy. The old administrator is fired and an interim administrator is appointed. In reviewing the accounting AIDS . Acronym for autoimmune deficiency syndrome. A deficiency in immunity caused by an infection. Business office manager . The hospital manager responsible for the creation, management, and collection of patient accounts receivable. Chief nursing officer (CNO) . The director of nurses. Medicare . A federally funded program that pays the costs of healthcare for individuals sixty -five year s and older. Revenue . Funds that flow into an organization because of the sale of goods or services. 78 records , he finds that $125,000 of overpayments by patients have never been returned. If the hospital returns the money , it will be unable to meet payroll and will have to close. The hospital is old and will never be reopened , as it does not meet fire and safety code and is operating under a waiver. It is the only hospital within 50 miles of the community and is the largest employer in the community. If the hospital closes , 200 people will be thrown out of work. In addition , a ne w manufacturing company that is looking closely at the community will locate elsewhere. The new jobs from the plant, if it locates in the community, would raise the local population to the point where the hospital might be able to survive. The controller p roposes to show the overpayments as revenue and not return them to their rightful owners , the patients. Who are the stakeholders and what are the ethical issues? 79