Hospital (33 page)

As the scotch worked its magic, Davidson remembered his grandfather, a cutter in the garment industry. “He was a labor organizer. I knew about equity and legacy. I knew the community owns the hospital. I believe it in my bones. But that’s extraordinarily hard to live by day to day, in a very challenging environment where many a day you realize your aspirations for yourself are not being met by you. That is humbling.”

Davidson would be well cast as a distracted, curmudgeonly, brilliant, arrogant, amusing (or irritating) academic; he once told me he had imagined himself in exactly that role. “At the end of the day, I wanted to play pontificating professor, puff my pipe, drink my tea, have a little less crazed existence, compete on the intellectual front, and get some of the recognition I perceived my old man got walking down Spruce Street by Pennsylvania Hospital [in Philadelphia], big fancy hospital. Everybody in the neighborhood knew my dad,” Davidson said. “He was in clinical practice, he did teach, he was on the faculty at the graduate school of medicine at the University of Pennsylvania until he died.”

Davidson intended to become a research chemist but went to medical school, like his father. At heart he remained a data guy, not much on bedside manner, preferring to improve patient care through systems that built efficiency. Self-aware, though. “I’m not the smoothest, most sociable kind of fellow,” he said. “I can be a prickly, opinionated kind of character.” He went to Wharton Business School. He read studies of how Disney World used an engineering approach to help the park deliver fun more systematically and profitably. He read about combining management and medical measurement tools. For eleven years he was the medical director for the City of Philadelphia Emergency Medical Services System.

In 1995 he got a call from a headhunter and went to New York to meet Stanley Brezenoff, who had then been at Maimonides all of four days. “I met Stanley at lunch, and within ten minutes I knew I could work for this guy,” recalled Davidson. “He said to me, ‘Steve, I’m here four days, and all I’ve heard is how terrible the ER is. The community, the medical staff, my administrators. Not only are my administrators telling me how terrible the ER is, they’re telling me how to fix it. If they know how to fix it, why is it so fucking terrible? We’re going to fix it, because it is so important to this community. ’”

Davidson saw opportunity in Brezenoff’s determination. Hospitals had finally discovered W. Edwards Deming, the management guru, and his “continuous quality improvement” model, with emphasis on interdisciplinary teams. Japanese car companies started using it in the 1950s and 1960s and went on to lead the industry. Davidson wanted to try Deming’s methods at Maimonides.

Davidson understood hypothetically what Brezenoff meant when he said that the ER was “so important to the community.” Davidson did not understand, however, that in the ER, Hatzolah
was
the community. Or rather, the Hatzolahs, plural: Borough Park, Flatbush, Williamsburg all had their own branches with their own leaders.

“Stanley didn’t make it plain how much working with Hatzolah was my responsibility,” said Davidson. “He buffered that from me greatly. There were times he suggested I make more phone calls to them. I did. Stanley calculated correctly that my general motivation to make things better would deliver what they required, so he didn’t emphasize the courting of Hatzolah. If that had been said to me in February, March, May, of 1995 while I was negotiating, it would have been a turnoff, and I wouldn’t have taken the job, and that would have been a mistake.”

In the ten years he’d been chief, emergency-room volume had increased almost 70 percent. In just the first year, without an increase in the budget but with rearrangement of shifts for doctors, nurses, and clerical staff, the number of ER admissions grew to 68,000 from 50,000. By 2005, the number was 82,000.

Davidson associated the increase in numbers to continuous quality improvement, the triumph of his systems, but the Hatzolah coordinators believed they controlled the switch. Davidson admitted he didn’t know how to concede the point, even a little.

“I’m a logician,” said Davidson. “It’s my impression that when I talk about how we did it, people’s eyes glaze over. I used to enjoy going out to Hatzolah and these other community groups and watch Stan Brezenoff do these great spiels. It was admirable, and I’d be so envious. I just can’t do that shtick. I’m pretty proud of what we’ve accomplished, but the challenge I face right now is the expectation of comparable improvement. Well, I’ve squeezed the rag drier sooner. It’s getting a lot harder.”

Barbara Sommer, a calming, eye-in-the-hurricane presence, longtime director of nursing for the emergency room, had been promoted the previous July and hadn’t been replaced. Her absence represented a double disappointment. For three years Sommer had been in charge of the hospital’s application to be accepted in the Magnet Recognition Program, developed by the ANCC, the credentialing branch of the American Nurses Association, to recognize health-care organizations that provide nursing excellence. Only 4 percent of health-care organizations achieve Magnet status, whose prestige was an invaluable attraction in an era of chronic nursing shortages. The application process is long and arduous, requiring volumes of documentation covering patient-satisfaction surveys, nursing research projects, and peer review. Once a hospital is part of the Magnet program, someone has to be in charge of maintaining the standards that got it there. Sommer was designated that person.

Sondra Olendorf, head of operations, had cause for optimism when she promoted Sommer. The hospital’s lengthy narrative analysis was deemed sufficiently excellent by the ANCC to take Maimonides to the final round, a site visit. Eighty percent of the hospitals that get this far become part of the Magnet program. But once again Maimonides was relegated to almost-as-good-as. The hospital didn’t make the final cut. Now Sommer had a better title but no clearly defined job, and the emergency room didn’t have Sommer.

Davidson had recently hired a nursing manager, a position that had been vacant for two years. He considered himself lucky to get anyone who was qualified. With a national nursing shortage, candidates were not knocking down the door to take over an emergency room jammed with acutely sick patients speaking numerous languages. Davidson said he thought Ann Marie Ceriale had “some great leadership chops.” When he tried to intimidate her, she didn’t let him. “She got red as a beet and pushed back,” he said. Guts she would need, he said. It would be rough for her, especially because, with Sommer gone from the department, he had no one to train her.

“We are at a very important transition time for nursing in the emergency department,” said Davidson. “There is a large cadre of staff who has an intimate relationship with Barbara Sommer, built over many, many years. They know each other’s families, the way each other thinks, their failures and heartbreaks. At the same time, there’s a new, young, eager nurse manager who will be quite challenging for the staff, and the staff is going to be quite challenging for her. And the most important mentor for her, a nursing director, is nowhere to be seen.”

In December, Davidson thought he had finally found someone willing to take Sommer’s place, someone who could train Ceriale, among a million other things. The candidate was a nurse director at another big Brooklyn hospital’s ER. Sommer interviewed her and thought she could handle the job. When questioned as to what she knew about Hatzolah, the woman said no problem, she and Hatzolah got along well.

Davidson decided to hire her. But when he told Douglas Jablon, Jablon told Davidson he should call Bernie Gips, one of the coordinators of the Borough Park Hatzolah. Gips would later say—with sharp-pronged tact— he felt she wasn’t the right choice. “She’s a very nice person, competent, but two and two doesn’t always add up to four,” he said elliptically. He felt he had conveyed his message to Davidson, and nothing more needed to be said.

This courtesy call, as Davidson thought of it, became the opening volley in a round of accusations and counteraccusations that wound up with Davidson withdrawing the job offer and eating a large piece of humble pie, washed down with a big gulp of scotch.

Douglas Jablon was furious because Davidson hadn’t consulted him about the delicate diplomacy required to approach Hatzolah. Bernie Gips was insulted that Davidson hadn’t listened to him about the nursing-director position. Davidson thought he had fulfilled his obligation by putting in a call to Gips.

When the contretemps blew up to the executive offices, Brier was not pleased.

“Stupidity,” she said. “These ER people really don’t get it. Well, they get it, but they don’t get it. This has been true since Stanley was there. Steve Davidson will tell you the day I sat him down after I took over and said, ‘You are not doing X and Y and Z. If you don’t do that plus ABC, you are not going to make it here.’ He said, ‘Stanley never told me that.’”

In her view, Davidson needed remedial training in community management. She recounted the story.

“Whereupon I called Mark McDougle and said, ‘Mark, Douglas is in meltdown. Can you call Douglas and calm him down?’ So he did. Meanwhile, I talked to Steve and said, ‘Steve, Douglas is very upset.’ ‘Why?’ he said. ‘I love Douglas!’ I said, ‘Steve, you went and chose the ambulance person after Douglas told you Bernie didn’t like her,’ and Steve said, ‘I guess the lesson is, I should just take matters into my own hands.’ I said, ‘
No,
actually, the message is just the reverse. You’ve got to make Douglas feel like the player that he is, because he’s working his little heart out to smooth things over and make things good, and to the extent you don’t go through him, you make him look bad. He found out about the supervisor-person hire from them! That’s bad. He shouldn’t. Could you just call him?’”

She concluded, “When I talked to Douglas a while later, I asked, ‘Did Steve call you?’ He said, ‘I didn’t return his call.’ I said, ‘You must return his call. You must let him apologize.’”

Jablon felt betrayed by Davidson, but his sense of betrayal paled next to his fear of Brier. “In front of both of my bosses, he let them believe I didn’t take care of the situation, which I did. I would never treat anybody like that,” Jablon told me. “But then Pam said [he paused] Steve apologized [another pause], and I kissed him [long pause], and that’s that.’”

Later I asked Bernie Gips and Elliot “Lazer” Rosman, the Borough Park Hatzolah coordinators, about the incident. Rosman, a gray-haired, intense man, was director of disabled students at Queensborough Community College; Gips, who tucked his side curls behind his ears, was president of a commercial air-conditioning business. (They both exuded the excitability that once led me to ask a Hatzolah volunteer why the Orthodox always seemed so nervous. Without hesitation he replied—grinning, “Because God gave us nerves!”) Jablon was the liaison for our meeting. He invited us to use his office, made introductions, left, and then returned briefly to deposit a box of cookies on the table.

“In the same breath I’m criticizing, I want to defend,” said Gips, who spoke so rapidly he wheezed as though he were running, not sitting. “They have a very good computerized system. But you have to have the doctors to go on the computer and check it. What good is it if the doctor doesn’t enter the order in the computer, the nurse doesn’t read the orders, and then the patient doesn’t get the right medications? The system is overwhelmed.”

How would he fix the emergency room?

Gips hesitated, just for an instant. “Couple of things,” he said. “I would change certain personnel.”

Who?

“You’re putting me on the spot. Certain personnel.”

Who?

“You know what they say?” asked Gips. “The fish stinks from the head. Let me just say that.”

Rosman chimed in. “That person, for example, he has certain expertise. He is a computer genius, and this makes him look good. This is very nice for patient information, but it doesn’t relate to what we call in Yiddish
nisht mayn a’khaver
[‘not my friend’].”

What was this, a Harry Potter story, talking about Lord Voldemort, “He Who Must Not Be Named”?

Neither of them corrected me when I asked if either of them had told
Davidson
directly that they didn’t approve of the nursing director
Davidson
wanted to hire.

“Not me personally, but someone let him know there might be a problem,” said Gips, whose face was flushed; he had a reputation as a hothead. “I want to ask you a question. Anyone trying to work with the community—and we bring five hundred patients a month, four hundred patients, which turns into big dollars—is it worth it to take on a fight? Is there only one person to take her place?”

Gips shook his head. “He talks to us without respect.”

When Brier called McDougle to deal with the situation, he once again was reminded that Maimonides was not like other places he’d been. “Everybody knows everything about everybody,” he said. “It’s very bizarre.”

“I’ll never forget Bernie’s first comment to me,” he recalled. “He said, I’m going to be a pain in the ass.’”

Gips fulfilled his promise, but McDougle didn’t really mind. He admired Hatzolah. “Other ambulance drivers come, it’s their job,” he said. “Hatzolah are volunteers, and they are like advocates for the people they bring. It’s like everyone comes with an advocate. ‘Why is the doctor taking so long? Why are the lab techs taking so long? Why is the medication not being given? Why is the radiology exam not done?’ They stay there. It’s the difference between being not just an ambulance person but an advocate. And they felt that this person [the nursing-director candidate] hadn’t been sufficiently sensitive.”

But he was also sympathetic to the pressures in the ER. “I do believe that everybody who works there is part saint,” he said. “When things don’t go perfect, there’s a lot of blaming. So not only do these people have to deal with sick patients, old patients, not enough space, too much noise, they have people running around blaming everybody for why it’s that way.”