By Tracy Weber, Charles Ornstein and Steve Hymon
Times Staff Writers
December 23, 2004
That's an opinion shared by most of the two dozen healthcare experts The Times asked for solutions to the county-run hospital's long-standing problems.
"If they don't delegate the responsibility and step aside, it's going to be a nightmare," said Dr. Ron Anderson, chief executive of the Parkland Health and Hospital System in Dallas.
Handing over control to an independent board or healthcare professional would be the best way to ensure that good medicine takes precedence over King/Drew's polarizing politics, said many of those consulted.
The Times talked with leaders of the nation's largest public hospital systems, national accreditors, and experts in hospital management, human resources, patient safety and nursing. In addition, the paper interviewed elected officials and others familiar with King/Drew's politics.
They were asked to suggest remedies for problems detailed in a five-part series, "The Troubles at King/Drew," published by The Times two weeks ago.
A yearlong investigation by a team of reporters determined that errors and neglect at the 32-year-old facility in Willowbrook, south of Watts, had repeatedly harmed or killed patients. Entire departments at the hospital, founded with high hopes after the 1965 Watts riots, were found to be rife with incompetence, infighting and, sometimes, criminality.
The failings cannot be ascribed to sparse funding, as the hospital's supporters often have done. The Times found that by the standards of most public hospitals in California, King/Drew is well-funded. The money, however, is often wasted.
The hospital's governing body, the five county supervisors, has been told of the problems repeatedly. But for years it has backed away from decisive action when faced with activists' anger and accusations of racism. So the problems at King/Drew, most of whose patients are impoverished African Americans or Latinos, have become entrenched.
There are no pain-free cures, the experts told The Times. All potential remedies face barriers, even active resistance. But they are worth trying, on their own or in combination, they said.
"I see this as kind of like a person who has a very bad — but curable — illness," said Dr. Donald Berwick, president of the Boston-based Institute for Healthcare Improvement.
Dr. Robert Wachter, chief of the medical service at UC San Francisco Medical Center and co-author of a book on medical errors, was equally pragmatic.
"Nobody's aspiring to turn this into the Mayo Clinic," he said, referring to the renowned facility in Minnesota. "That ain't going to happen. Everyone should try to turn this into a place where you wouldn't panic if you're told that's where the ambulance is taking you."
Successful reform depends heavily on the commitment and good will of the people involved, from the county supervisors to low-level hospital technicians, the experts cautioned. It almost certainly would require changes in staffing, policy and, perhaps, law.
The supervisors say they already have taken a dramatic step. In October, at a cost of $13.2 million, they hired Navigant Consulting to identify and begin making changes over the next year. The hospital turnaround firm's blueprint for action is due Jan. 3.
But many of those interviewed said bringing in consultants was the easy part.
"They're not the ones that are going to stay there and fix the place in the long term," said Dr. Kenneth Kizer, California's former health director and now chief executive of the National Quality Forum, a patient-safety group in Washington, D.C.
For fixes to last, said Los Angeles civil rights attorney Connie Rice, they need to be farsighted, even drastic.
"Don't bring in this consultant to do tooth whitening and flossing," she said. "We need root canals and dental implants."
Create new oversight
More than anything else, the experts said, the county supervisors must cede control to people with the time, inclination and know-how to improve treatment at King/Drew, regardless of political backlash.
The supervisors officially delegate operation of the county's five public hospitals to the Department of Health Services, but they have intervened sporadically, usually for political reasons, the Times investigation found. When problems have erupted publicly, the board has often endorsed half-measures, not wholesale change.
"Some kind of oversight group has to take control of the place," said Gail Warden, president emeritus of the Henry Ford Health System in Detroit. "You can't fix any of it unless somebody is put in charge who has the will to do it."
This could be accomplished in one of several ways, the experts said. The county could:
Ask the state Legislature to create a health authority — a separate body that would have complete control over all the county hospitals. The authority's members could include local medical school deans, presidents of private hospitals and successful corporate leaders. To avoid political patronage, they could be appointed or screened by a special commission.
Appoint a separate oversight board for each of the five county-run hospitals, letting the boards make management and funding decisions. Each would have independent auditors at its disposal to ensure accountability.
Appoint or elect an independent "surgeon general" to oversee all the hospitals. This person, with expertise in hospital management or medicine, would operate much like the sheriff or district attorney, in control of day-to-day decisions. The supervisors would set the budget, but their overall role would be greatly reduced.
In any case, the county board cannot — or should not — continue in its present capacity, most experts agreed.
A new oversight group will be a key recommendation of a steering committee, funded by the California Endowment philanthropy group, that has been examining the hospital for several months.
"I don't know whether the embarrassment of King/Drew has been sufficient to get the Board of Supervisors to go back and say, 'We need to create a buffer there,' " said Dr. Cornelius Hopper, chairman of the committee. "At a certain point in time it would seem to me they would welcome a buffer."
Should the supervisors agree, the changes would probably apply to the rest of the county's hospitals as well, which would be costly, time-consuming and perhaps controversial. Many experts say the system could use such sweeping reform, although none of the other facilities has problems as serious as King/Drew's.
Some caution that shifting responsibility elsewhere does not always work. It sometimes just adds another layer of bureaucracy, without guaranteeing independent management.
Denise Martin, president of the California Assn. of Public Hospitals and Health Systems, resigned from the Alameda County health authority's board because, she said, county supervisors never stopped interfering.
"Health authorities are not a panacea," she said. "It's too easy to have a finger-pointing situation when you have two different boards, each saying, 'It's not my fault,' when something goes wrong."
Whatever Los Angeles County decides to do, several experts said, local business and medical leaders need to take an active role in improving King/Drew and the entire county health system, which overall faces a huge funding crisis. The experts point to the success of healthcare advocates in Dallas and Chicago — even to the way Los Angeles civic leaders have taken an interest in the city's troubled school district.
State politicians and health regulators also need to assume a more active role, one official said.
Considering that Los Angeles County is the most populous in the state, "if I was the [state] health director, I think I'd call and say, 'What are you clowns doing down there?' " Supervisor Gloria Molina said.
Refocus the mission
Regardless of the supervisors' role, the experts said, King/Drew may need to redefine its mission.
"I think the purpose should be, or could be, to improve patient care for the community," said Dr. David Leach, executive director of the Accreditation Council for Graduate Medical Education, which oversees teaching hospitals nationwide. "It's not clear that is the purpose. The purpose may be to provide jobs."
Many of those interviewed said King/Drew might be trying to do too much — juggling specialty care and a host of physician-training programs — and falling short on the basics.
The medical center should provide the services that its patients really need and that its staff is qualified to perform, experts said. That might mean scaling back to the level of a community hospital, rather than being a full-service teaching institution.
Several experts suggested that King/Drew focus on medical conditions that disproportionately affect minority communities, such as hypertension, diabetes, asthma and congestive heart failure, and for which these groups typically receive inadequate care.
Richard Berman, president of Manhattanville College in Purchase, N.Y., and a former state hospital regulator in New York, suggested that King/Drew be converted into 24-hour outpatient clinics for medical conditions that commonly afflict the community.
"Think of asthma," Berman said. "You could provide a lot of inhalers for the cost of one inpatient day."
Changes to the hospital's mission must be accompanied by a shift in attitude among its most vocal supporters, who often defend the status quo, some experts said.
"It's going to be sustainable only if there is a community that says, 'We deserve good healthcare and we demand good healthcare,' " said Hopper of the California Endowment-funded steering committee. "It doesn't do you any good to defend a hospital where people are dying."
King/Drew needs a strong and independent administrator — chosen purely for talent — with the authority to root out incompetence and misbehavior throughout the staff, many experts said.
The Times' investigation found some of King/Drew's employees to be among its most intractable problems. The hospital is plagued by absenteeism, inattention to duty and, occasionally, violence.
"There's no teacher in the room," said Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, which inspects hospitals nationwide. "Why are we surprised that kids are throwing chalk and erasers?"
Some experts recommended — even if there were a new administrator — a short-term suspension of Civil Service and other personnel rules, which require extensive documentation before an employee can be disciplined.
"Culture change in a place that is that broken does involve heads rolling. There's just no question about it," said Wachter of UC San Francisco. "Everyone from a hospital clerk to a highly paid doctor, if they're not doing their job, they're fired."
Scrapping Civil Service, however, is not easy. It would probably require forming a hospital authority, securing an agreement with unions or amending the county's charter through an election.
And some experts said the Civil Service system itself wasn't at fault. Rather, they blamed hospital managers who didn't do what they should have: routinely document employees' poor performance and apply appropriate sanctions, so that when suspension or firing was warranted, they could prove it.
"If you have a good manager, you don't need to suspend anything," Jean Ann Seago, director of the UC San Francisco nursing administration program.
Reform is not just a matter of punishing or jettisoning poor performers, however. The county must also pay competitively and give prospective employees financial incentives to apply at King/Drew in the first place, several experts said.
Another potential draw — or drawback — is a hospital's image. Medical professionals might join King/Drew if they felt it was a place where they could help people who needed them most.
"That's why people come to a lot of the troubled systems," said Dr. Benjamin Chu, president of the New York City Health and Hospitals Corp. "They see a tremendous opportunity to maybe make a difference. And you can; that's the crazy part."
Find a new training partner
Several experts question whether King/Drew and its affiliated medical school should continue training doctors to be specialists while the hospital is in such disarray.
"You can't train residents in this type of environment," Kizer said. "At least, I shudder to think of what they're being trained" to do.
King/Drew's residency programs — run under contract by the Charles R. Drew University of Medicine and Science — won't attract top applicants until the hospital itself improves, several experts said.
Six of 18 training programs have either been ordered to close or could face sanctions. And the hospital is the only one in America to have received the lowest possible rating in the last two reviews from the Accreditation Council for Graduate Medical Education.
Removing the training programs could take pressure off King/Drew as a whole. But some experts said such a drastic move would undermine one of the hospital's earliest and highest aspirations: to train minority doctors so they might serve long-neglected communities.
And Drew University officials say they have taken important steps, such as reforming their board of trustees, to improve their programs.
Even so, several leaders with experience running academic medical centers found fault with the performance of Drew, whose faculty supervises the residents' training at the hospital.
Many of those interviewed, including politicians, consultants and hospital leaders, said UCLA and USC would be better partners for King/Drew because they already run successful training programs at other county hospitals. The two schools have agreed to provide advice but have balked at further involvement — a stance some experts found unacceptable.
"I think that's an abrogation of responsibility," said Anderson of Parkland, the public hospital in Dallas.
But Dr. Brian Henderson, dean of USC's Keck School of Medicine, countered that "it would be beyond our resources to try to do something like that. UCLA might be in a much stronger position, with more depth than we have."
Not so, said Dr. Michael Drake, the UC system's vice president for health affairs. "The county has to make the hospital viable," he said. "The university just doesn't have the capacity to do that."
Dr. Robert Ross, president of the California Endowment, said fixing King/Drew's training programs might require UCLA's involvement.
"It may be necessary not to have UCLA volunteer but to draft UCLA to provide some kind of oversight," he said, and perhaps enlist local members of Congress and state legislators to apply pressure.
Issue a report card
King/Drew must find ways to hold its physicians and other employees accountable, hospital and medical experts said.
David Thornton, executive director of the Medical Board of California, said King/Drew historically had not done enough to review mistakes that harmed or killed patients.
In the last five years, he said, the hospital has referred only one physician to the state for possible discipline, far fewer than other hospitals, many with better reputations. Thornton and other experts said King/Drew's peer review system, in which doctors examine each other's mistakes, needed to be completely revamped.
"They need to look at some other institutions," such as Cedars-Sinai Medical Center on Los Angeles' Westside, "that do it and do it well, and learn from them," Thornton said.
Another possibility is having outside reviewers assess King/Drew's quality of care until doctors there show themselves up to the task, the experts said.
Some said the hospital needed to make itself more directly accountable to the public as well. One option is to publicize information on how the hospital performs, including its complication rates for various medical procedures and its workers' compensation costs.
Rather than singling out King/Drew, such a report card could be compiled for all of the county's public hospitals and made available online.
Dartmouth-Hitchcock Medical Center, a private teaching hospital in Lebanon, N.H., posts on its website such information as mortality rates, breast cancer survival rates, the thoroughness of doctors' exams and whether patients were given pain medications promptly.
A county report card could also include the amount spent on medical malpractice and overtime — for which King/Drew has historically paid out more than other county hospitals.
Public accounting would probably enhance performance, said Leach, head of the group that accredits doctor-training programs. "The nature of human beings is to improve what is measured."
The hospital cannot reinvent itself from the bottom up without closing temporarily, several experts said.
"The best way to try to fix it is to give it a rest," said Berwick, president of the Institute for Healthcare Improvement. "This could emerge as a dramatic success story. But only if they invest the time to redesign it."
Once it was closed, experts said, the county and hospital leaders could retrain staff members who were competent and fire those who weren't, hire new workers, institute new procedures and thoroughly clean, patch and paint the hospital.
"Whatever is done, you're going to have to do it one thing at a time," said Seago, the nursing expert. "You're going to have to focus on a given unit and get that unit straightened out."
The hospital could then, perhaps after six months, reopen gradually, she and others said.
Most of those interviewed acknowledged, however, that closing the hospital, even temporarily, might prove politically unfeasible. The county supervisors have said repeatedly and publicly that they have no plans for closure, and a temporary shutdown would probably fuel fears of a betrayal.
"I think you'll turn the community against you," said O'Leary, head of the national accrediting group. "You'll lose your opportunity to engage them."
Kizer, the former California health director, said temporary closure also posed practical problems. "My fear is: Where are people going to go for the next six months?" he said.
Instead, he suggested, the hospital could temporarily cut back to its most essential services, then branch out again as reforms took hold.
Most experts did not suggest permanent closure. But Wachter, co-author of a recent book on medical errors, said he would not rule out that possibility entirely. The county health department, he said, needs to pick 15 to 20 ways to measure the quality of care at King/Drew and set appropriate goals in each category to ensure patient safety.
Then the supervisors, he said, should take a pledge: "At the end of three years, if we're not achieving this level of performance on these outcomes, we all agree we are closing the doors."
For the sake of the lives of the poor folks who live in the Watts area, I think that the hospital should be taken over by federal authorities or should be shut down. There comes a point where we must understand that all life is valuable and must not sacrifice it for silly notions of both racist bureaucracy and white folks out to do harm to minorities. -- David Anthony Cort, Inglewood
The supervisors need to accept the fact that their failed leadership has not been able to enact change and that they now need to bring in and empower outside professionals who know how to turn around problematic hospitals. They need to get out of the way and sell this solution to the community. -- Mark Whalen, Trabuco Canyon
I must caution that unless each and every one of us recognizes that King/Drew Medical Center is not a black or brown issue but an issue that reflects on all county residents, then we will not witness a true renewal of a necessary link in the vital healthcare safety net. -- Felix L. Nunez, MD, medical director,South Central Family Health Center, Los Angeles
My suggestion is to lay off the entire staff, close the hospital, give the physical plant an upgrade, and hire a new staff based solely on competency, without respect to race, color or creed. -- Pamela Price, MD, San Diego
The L.A. County Civil Service system both aids and abets the problems at King/Drew . When is someone in county government going to wake up to the fact that there need to be drastic reforms in Civil Service rules so that employees that clearly should be terminated for unacceptable performance can be let go without having to navigate through a maze of bureaucratic rules and procedures? -- Bruce C. Dunklin, Northridge
It is critical that while consultants work to stabilize the hospital, every level of government commits to not simply "saving" but also to "rebuilding" the hospital . While quality of care must be improved, the answer cannot be through the elimination of services in a community with limited access. -- Lark Galloway-Gilliam, executive director, Community Health Councils, Los Angeles
On the Internet
The five-part series, "The Troubles at King/Drew," including photos and additional information, is on the Times website at latimes.com/kingdrew.
The newspaper welcomes comments from readers. These may be sent to firstname.lastname@example.org.
Times staff writer Mitchell Landsberg contributed to this report.
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