Rolling the Healthcare Dice

December 6, 2013
Eric Postal, MD

The powers that be often already know the ticking time bombs around us, but have decided they'd rather gamble and clean up the mess later.

A friend of mine works in a moderate-sized healthcare facility. Not a physician, but nevertheless an advanced-degree professional. During our frequent discussions (even before the current healthcare law and its attempted rollout), it's always been interesting to compare and contrast our experiences in the field.

We're both in a kind of middle layer of personnel around which such facilities - hospitals, long-term care residences, rehab units, etc. - are built. One might consider the upper layer to be administrative types (CEO, COO, etc.), and the lower layer to be the support staff (much of nursing, PCAs, housekeeping).

A frequent theme of our shared anecdotes is that the middle layer, despite being the backbone upon which our facilities operate, has the least clout. Admins make the big decisions, and while the support folks are commonly unionized and have some measure of protection against administrative moves (compensation cuts, increases in responsibilities, etc.), middle-layer types do not.

What we do get, in abundance, is the burden of somehow making it all work; no matter what resources we are given. A patient load two to three times above the reasonable range. Responsibilities that cannot possibly be met in normal working hours, and no mechanism for overtime or other redress. Nominal "authority" over support staff without a viable means of actually depending on it.

We therefore often find ourselves with just the right perspective to see weak spots in the facilities' systems, places where breakdowns are likeliest and in fact seem inevitable -postoperative patients attempting to walk to restrooms unassisted because recovery room nurses are overtaxed, for instance. PAs and NPs seeing patients in lieu of physicians, sometimes even taking the place of subspecialty consultations.

The more idealistic (or, at least, greener) inhabitants of our middle layer, including ourselves in years gone by, see these threadbare elements of our workplaces and get concerned, anxious, and/or angry. Not just because our names and credentials are on the record if anything goes wrong, but because somewhere along the way we were given the idea that we were members of a team and were expected to do our part to maintain and improve the facilities in which we worked. (To say nothing of wanting patients to get better care.)

And then, sooner for some than others, we see that we're shouting into the wind. The powers that be already know about the ticking time bombs we see all around us, but have decided that they'd rather gamble. Take a chance that the potential disasters we see will never actually happen, or that it'll be cheaper and easier to clean up the mess afterwards rather than preventing it in the first place.

Risk a Medicare audit in the future by engaging in more profitable (or less costly) practices now. Roll the dice on facing a med-mal lawsuit down the line, because hiring fewer staff and overworking them keeps more blank ink on the ledger. Or even charting a course for future catastrophe because the chips will fall after the CGO (Chief Gambling Officer) of the facility knows he's retiring next year, and the mess will be in the lap of his successor.

We shouldn't judge our CGOs too harshly. They are, after all, operating in an industry where it is pretty much necessary to cut as many corners as you can to remain viable, let alone competitive. They also have numerous layers of personnel separating them from the daily operations of their facilities, and only know what they're told via easily fudged paperwork or committee meetings (typically attended by others not actually in the trenches or aware of just how often the dice are being rolled). Which works well enough for the CGOs; the less they know, the more plausible deniability they potentially have when the dice turn up "snake eyes."

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