When I moved to Orange County in 1972, I joined a friend from my surgery residency in practice at a new hospital that had opened a year before. It was called “Mission Community Hospital,” and was owned by a group of doctors with one of the partners an owner of the new development of Mission Viejo. His name was Richard O’Neill and his family had developed Mission Viejo from part of their huge ranch.
The hospital was small with 110 beds total and the staff was made up of young doctors who had recently finished their training like me. The owners were mostly older doctors and practiced in another area of the county. Some of them we would not have allowed on the staff if they had applied. They largely left us alone and over a period of a few years we developed what we thought was the best hospital in Orange County.
Mission Hospital in 1975.
This is what the hospital looked like in 1975. The swallows used to nest in that entry area. To the right of the entry, there was a doctors’ parking lot and, for a while, the hospital paid a kid to wash our cars. Tom and I always tipped him extra. The food in the doctors’ dining room was free and good and I got a bit pudgy. The hospital went to considerable trouble to make it friendly to doctors and we responded.
In 1979, an article was published by two surgeons about trauma care in Orange County. They were critical and we resented this criticism to the point that the County Medical Association organized a project to review the records they had used and see if their facts were correct.
Archives of Surgery. 1979 Apr;114(4):455-60.
“Systems of trauma care. A study of two counties.”
West JG, Trunkey DD, Lim RC.
Cases of motor vehicle trauma victims who died after arrival at a hospital were evaluated in both Orange County (90 cases) and in San Francisco County (92 cases), Calif. All victims in San Francisco County were brought to a single trauma center, while in Orange County they were transported to the closest receiving hospital. Approximately two thirds of the non-CNS-related deaths and one third of the CNS-related deaths in Orange County were judged by the authors as potentially preventable; only one death in San Francisco County was so judged. Trauma victims in Orange County were younger on the average, and the magnitude oftheir injuries was less than for victims in the San Francisco County. We suggest that survival rates for major trauma can be improved by an organized system of trauma care that includes the resources of a trauma center.
Don Trunkey was chief of surgery at San Francisco General Hospital and an advocate of regional trauma centers. He is now (I think retired) chairman at Oregon.
I reviewed many of those cases and came to the rather reluctant conclusion that they were correct. We could do better. Furthermore, I was sure that the county supervisors would regionalize trauma. We wanted to be part of that if it happened. I got a chance to meet with the Board of Directors and convinced them to spend the time and money to apply. If trauma, which was not a high priority for most doctors, was regionalized, other things could be as well, like heart surgery or even joint replacement surgery, then pretty new.
They agreed and hired some consultant to write a proposal. When I saw the completed version, it looked like prospectus for a shopping center. It had to be rewritten and there was no precedent for a small hospital trauma center. All the ones I knew of were university hospitals, like San Francisco General, made famous by the movie “Bullit.” I rewrote the proposal and got input from as many hospital employees as I could. For example, we could not afford to staff the hospital with doctors and extra nurses waiting for a trauma case that might arrive twice a week, which was in fact our early experience.
What we did was invent a couple of new jobs. The hospital had a 24 hour pharmacy and, when we asked them, the pharmacists were very enthusiastic about being part of the trauma team. The nursing issue was a little more complicated. We could not keep a nurse in house waiting for a trauma and we could not overload the ICU nurses on duty, but I had seen how useful an ICU trained nurse could be when my wife, who had been an ICU nurse, came with me to the hospital one time (We had been out to dinner when I was called) for a ruptured aneurysm patient. She put on scrubs and, even though she was not an employee of that hospital, she was a huge help to the anesthesiologist.
We asked for volunteers from ER and ICU nurses who were willing to be on call at 15 minutes notice and got quite a few. Most of our staff and the doctors lived near the hospital. The nurses who volunteered were cross trained in ICU, ER and OR so they were all comfortable in working in all settings. When we began the trauma center, a Trauma Nurse would come in and take over care of the patient in the ER, releasing the other ER staff back to their duties. She would then accompany the patient in ER, to x-ray, to the OR, and sometimes back to x-ray, until finally the patient was turned over to the ICU nurse. Some of our trauma cases spent 24 hours from admission to the ICU before the trauma nurse was released. They loved it and we had no complaints. Their call pay was a small fraction of the cost of a full time nurse in house.
The commission that was assigned to inspect the applying hospitals was made up of big hospital trauma surgeons and they did not expect to see much in a small suburban hospital. There were five applicant hospitals in Orange County, one of which was the UC, Irvine hospital. When the survey was complete, we had scored the highest of the five, including the university hospital.
The trauma center got gradually busy over the next seven years. We added additional surgeons to the surgical group so we would have enough to take the necessary call. Finally, by February 1986, I had had enough. My back, which I had broken in college, was giving more trouble and the new members of our group still had to be monitored by one of the experienced partners. This resulted, in January 1986, of my spending three of four weekends on call and two stretches of 40 hours without sleep. I decided to leave the group and restrict my practice to non-emergencies, always a risk for surgeons’ referral practices. Fortunately, soon after this, the laparoscopic cholecystectomy came along as a new development and I was able to transition into this less physically stressful surgery.
The trauma center continued on without me and got busier as years went by. At last, in December 1993, my back problem was worse and I had to undergo surgery at UC San Francisco. After the surgery, which took 14 hours, I retired and turned my surgical practice over to a young associate. That summer, after a mildly complicated convalescence, I moved back to New Hampshire to indulge a long term interest in medical quality measurement and spent a year at Dartmouth Medical School getting another degree and learning some health policy. In June of 1995, I graduated, with my children in attendance, and made some plans to do research in medical quality improvement. The program was presented at a division called The Center for Evaluative Clinical Sciences. The Director, Jim Weinstein, was a classmate of mine in 1994-95.
When I finished the program, I was invited to stay and work on a research project. That project is described here. The project was not funded by the NIH, which seemed unable to understand how the analysis of Medicare claims data with statistical methods worked. The method has become much more common in health policy circles since then but I decided to go back to California where my family lives and pursue other ambitions. I did not resume medical practice but spent some time working on health policy research at UC, Irvine.
The Trauma Center continued along the lines I had established and the hospital was eventually sold to a nonprofit corporation run by an order of nuns who owned other Orange County hospitals. Some of the practices we had established, like the Trauma Nurse call program, were ended by a new administrator who seemed far more interested in his own salary than in the quality of care we had been providing. As the years went by, I saw evidence of an amazing growth in administration typical of non-profit entities.
About 2000, I became a member of the Planning Commission of Mission Viejo where I still lived. The hospital had expanded since I left and now another expansion was planned. I was particularly interested because of my previous experience and had an occasion to see just how far the growth of the administration of the hospital had extended. The hospital asked the Planning Commission to set aside an afternoon for the presentation of the plans. Another member of the Commission and I were asked to conduct this session. I was astonished at the number of young deputy administrators who showed up and the volume of material they planned to present. It seemed excessive and I finally had to leave after about three hours. That was a preview of things to come.
Mission Hospital today.
A few years after I had retired, more changes were made in the trauma center program. First, the call schedule of OR nurses was changed. They would no longer be paid for trauma call and they were expected to work weekends. The more senior nurses objected as night and weekend call had been part of the system for new hires. They had worked their way up to more senior status and felt they should not be required to go back to the schedule they had as probationers. The administrator dismissed their concerns in spite of warnings that senior experienced nurses would start to leave and go elsewhere that had no trauma center. Soon, the more experienced began to find other jobs. I wrote a letter to the LA Times about this which was published and prompted an angry phone call from the administrator. He told me that I was no longer working there and did not know the situation. I did, however, and in fact, 12 experienced OR nurses left in the next year after the change. Many left to go to surgery centers which had no night or weekend cases.
A couple more years went by and I learned that the hospital had laid off the low wage “environmental services” workers who cleaned the operating rooms between cases. Nurses, who made three or four times the hourly wage of the cleaning staff were now expected to clean rooms between cases in addition to their other duties.
In 2008, we began to see the anticipation of Obamacare. Hospitals began to expect tighter margins and, being the most incompetently managed large organizations in the US, they decided to reorganize with little idea of how to do so. They expected that vertical integration would increase their profits (Which are as large in non-profits and in for-profits) so they spent millions to buy the medical practices of doctors on the staff. This put the doctors on salary and bonus systems but there was a natural conflict of interest. Doctors had for many years been the object of frustration and even hatred from hospital administrators. We don’t take orders well and many resisted the efforts of the hospital to make us order either more tests, when it was profitable to do so, or, in recent years, less tests and less treatment that costs money. For example, 20 years ago after Medicare adopted the DRG payment system for Medicare, which pays a flat fee for a hospitalization based on the diagnosis only, we suddenly found that the same employees who had been selling unneeded services to our patients, were now telling them, and us, that they had been in the hospital too long.
Now, the employee doctors practice at the bidding of the hospital administrators and risk severe consequences if they do not follow orders. For example, my former surgery group which has run the Trauma Center for 35 years since I designed it, has now been arbitrarily replaced by another surgical group from another part of the state. The new surgeons are strangers and the OR staff knows nothing of their training or experience. The staff finally met the new surgeons last week and they are all women. They begin to take trauma call next Tuesday, July 1.
Why was this radical change made ? There is speculation that the surgery group was made “an offer they couldn’t refuse” last year when the hospital wanted to buy their practice and put them all on salary. They declined and this may be the result. The Emergency Room, which is another contract service between doctors and the hospital, has been told to refer patients only to the new group. It is anticipated that the medical specialists in the hospital owned medical group will be given similar orders. The surgical group found out about this several months ago and has begun to shift much of their surgery cases to the other large hospital in the area.
One other small fact might shed light on the story. The new administrator for the past several years had no health care background before becoming the Mission Hospital Chief Financial Officer in 1998. He came from Pepsi-Cola. His brother-in-law, a chiropractor, was placed in charge of the operating room. The new big medical center has not yet seen fit to announce the news of the new surgical group taking over. It will be interesting to watch what happens to medical quality over the next few years. I’m glad I am retired.
A gastroenterologist friend has told me of one new development. He has an endoscopy facility inn his office and has been using it for his procedures for 30 years. Now the hospital is pressing him to do more procedures in the hospital facility. He looked at some charts and found that all the cases had an excessive number of diagnostic tests ordered. This is an old scam and I guess it will become part of the new strategy for dealing with health economics these days. Ethics is for old guys and the naive.
Tags: health care
Fascinating read, as always.
More to come Charlotte. It’s evolving every day.
Very interesting. I lived in Mission Viejo right near that very hospital for a couple of years (2002-2004). I didn’t realize the O’Neill family had a started the hospital years ago. I wonder what you think of the expansion of the area. Is the Irivine Ranch Company owned by the O’Neill family. They have built out Ladera Ranch and are in the planning stages for many more new homes. I’d have made $200,000 in 2 years if I’d have bought in 2002 and sold in 2004 when I moved away but I was reticent to buy as I could see that Real Estate was going to blow up, I just couldn’t predict when.
Irvine Ranch was owned by the Irvine family. Rancho Mission Viejo was the O’Neill family ranch and was originally called “Rancho Santa Margarita” and originally extended from El Toro to Oceanside. The Jim Flood family sold their half to the Marine Corps in 1942 and it became Camp Pendleton. Mission Viejo Ranch ran from El Toro to San Clemente east of the railroad tracks. On the east side is Cleveland National Forest.