The following is the opinion of David L. Quincy.
On Tuesday, September 28th, the Senate Committee on Indian Affairs held an Oversight Hearing titled "In Critical Condition: The Urgent Need to Reform Indian Health Service's Aberdeen Area." The hearing came about because of a variety of concerns regarding IHS, particularly the Aberdeen Area and the Quentin N. Burdick Memorial Hospital. As a former CEO of that facility I feel that I am qualified to speak to some of the issues and concerned raised and discussed by this oversight hearing.
At the hospital, located on the Turtle Mountain Reservation in North Dakota, the Aberdeen Area IHS Office has placed about 10 CEOs in as many years there, four of which were supposed to be permanent placements. They were all charged with the task of efficiently and effectively administering the programs and services offered by that facility.
If the problems inherent to running a hospital were all that these CEO’s had to deal with, then most likely the facility would still have that first permanent CEO. But all of the permanent CEO’s placed at Belcourt in the last 10 years have either resigned, retired, or have been terminated, making that facility truly a career ending opportunity.
My own experience as Belcourt’s CEO began in August of 2007. I knew that the Service Unit was troubled one, but I was still optimistic and confident that I would make a difference, because of my education, skills, training and experience. When I left in January 2009, I felt defeated, my career at IHS at an end.
With the announcement by Senator Dorgan, that he was initiating a investigation into the IHS and specifically the Belcourt Service Unit and the Aberdeen Area, I began to reflect on my experiences there and realized that while I made mistakes, I was just one CEO in a string of individuals thrown into the mill, I am not even sure at this point if I was even expected to succeed, because while I did receive some area support, in other critical areas, I not only received no support, but was seemingly actively blocked from taking action or actions.
It was also clear that the Aberdeen Area management was aware of many of the core issues that were adversely impacting management at the Belcourt facility and ultimately the quality of services being delivered to the Turtle Mountain Reservation.
For example a 2007 evaluation of the nursing program at Belcourt hospital cited “Poor morale; Negative influences from managers”; and that nurses were “Afraid that they would be reprimanded and reported to the Board of Nursing” if they attempted to communicate their needs and concerns. The report also found that nursing staff’s schedules were changed without notification or following union rules, that staff often worked extra shifts but were not compensated with time off.
The report cited staff’s perception that preferential treatment by the Director of Nursing and nursing management staff, was given to some staff and that doctors were at times threatening to nursing staff. Attempts to address this situation, by for example, detailing the Director of Nursing out of the facility or addressing these issues through the personnel evaluation (PMAP) process, were not successful, primarily because of directives from the area office blocking these attempts.
In the November 2008 report cited by Senator Dorgan, the evaluator found that “The Clinical Director and Director of Nurses have used their position powers, both individually and collectively with their respective departments, through demonstrated disruptive behaviors to undermine the CEO’s position authority, and have intimidated other staff resulting in the general perception that there is no leadership or accountability at the hospital”.
Senator Dorgan directly cited the following statement that “The DON has created an intimidating environment with well founded fears of retaliation among nursing staff for speaking out against any of her decisions or behaviors”. Senator Dorgan expressed his dismay and outrage that not only was the DON not disciplined but was given a $4,000 bonus.
The report concludes with recommendations and the following “ The behaviors [the Clinical Director and the Director of Nursing] must be dealt with; it does not matter how experienced the next CEO is, he or she will not be successful because the two individuals have proven that they can effectively undermine the CEO and suffer no consequences. Eliminating the behaviors of these two employees is paramount to support the efforts of an experienced leader to help employees achieve some degree of insight and develop motivation for positive change that is once again patient focused”.
This report was prophetic. How many of the interim CEOs as well as the most recent permanent CEO failed because of these issues?
Despite this evaluation report -- along with other documentation of these and similar issues -- the Aberdeen Area office appointed new CEO but failed to provide the administrative and executive support necessary for the CEO to implement his or her proposed changes and directives.
It is also interesting to note that Ms. Red Thunder's response to Senator Dorgan about the DON was to shift attention and blame to the CEOs. As proof of her action, she cites the fact that six CEOs in the Aberdeen Area have been disciplined in the last few years.
She was less than honest by stating that such a internal review report would have generated a Corrective Action Plan (CAP), which the CEO did not follow. Not only was there not a CAP developed but a copy of the November 2008 evaluation report was not provided to the CEO despite oral and written requests for it. Instead the CEO was given verbal directives not to divert inpatient services and to conduct a witch hunt of facility employees who were speaking out against the Deputy Area Director.
At times the area office would micromanage the CEO and other times ignore them, both with equally negative results. A part of the responsibility lies with the personnel system, where employees have a great deal of rights, and taking personnel action against an employee requires a great deal of documentation. This does not prevent the Area Office from taking action, but it has come back against them when a action is falsely taken or when the right action is taken but in the wrong way.
At the heart of the issues and problems at Belcourt and to some degree Aberdeen, is personnel, their relationships and how they are intertwined with the normal day to day operations of the facility are what all of these CEO’s permanent and interim have had to deal with. These relationships do impact the delivery of health care in many, often subtle ways.
At Belcourt, most everyone is related to each other, these relationships are also intertwined with the community, Tribal Council, and with Aberdeen area staff (the 2008 report documents the fact that the DON has a relative working in the Aberdeen Area personnel office).
It should be noted that not all, not even a majority of these relationships have negative impacts. The positive side of these relationships is reflected in that same 2007 Nursing evaluation which stated that 90 percent of the nursing staff participating in the evaluation when asked “What is the most positive aspect of your work experience”? Responded with the statement “the patients and their satisfaction for their care”. This statement is also, I believe, reflective of the attitude and professionalism of the majority of the staff and management at Belcourt hospital, Aberdeen Area and IHS in general.
While some of these observations are a simplistic look at a complex, bureaucratic agency with equally complex underlying rules and regulations, it is my hope that the Senate hearing will cut through the blinders that the IHS leadership continues to wear when it comes to dealing with these issues throughout the IHS and not just Belcourt hospital and the Aberdeen Area, with end result of positive changes that will provide better services to Indian peoples.
HEARING titled, In Critical Condition: The Urgent Need to Reform Indian Health
Service's Aberdeen Area
(September 28, 2010)
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