|SAN FRANCISCO CHRONICLE
GENERAL: LIFE AND DEATH AT SAN FRANCISCO'S HOSPITAL OF LAST RESORT/
Chief executive pours heart and soul into S.F. General — but can she save it?
Mike Weiss, Chronicle Staff Writer
Wednesday, December 13, 2006
Gene Marie O'Connell, the chief executive officer of San Francisco General Hospital, was on the phone getting the kind of news that could mean the glass was either half full or half empty.
She was talking to her boss, city health director Mitch Katz. Many days, Katz oversaw the city's billion-dollar health budget wearing shorts and a polo shirt. Dressing down was something that a powerful man could get away with. O'Connell never dressed down on the job. She had on a tailored black pants suit with white piping, a white bead necklace and pumps.
She was at her desk, her slender shoulders hunched, her pale oblong face and quick hazel eyes a picture of concentration.
Katz's news was that the Board of Supervisors refused to set aside a lump sum of $25 million for planning a new hospital. Mayor Gavin Newsom wanted the lump sum, as did O'Connell. The mayor called building the new hospital to comply with a state-mandated deadline for a seismic upgrade "the highest priority of my administration."
But the supervisors had decided to dole out the money over three years, instead. The money will be used, in part, to get a reliable cost estimate put before voters in 2008 when they are asked to approve a bond for the new hospital.
In the wake of cost overruns and delays in rebuilding Laguna Honda Hospital and constructing the new Bay Bridge span, Newsom said in an interview that he wanted accurate and detailed planning before going to the ballot because, "We don't want to make the same mistake with San Francisco General, too much is at stake."
"I guess what everybody was afraid was that it would be hard to move forward on the rebuild plans," O'Connell said to Katz in her broad Quincy, Mass., accent that 30 years in San Francisco has not dented, "if we didn't get the full amount." Half empty.
Katz was doing most of the talking. O'Connell's eyes flicked to her unread e-mail, a batch of reports and memorandums waiting on her desk, and finally came to rest outside her window. On this March morning the fog was already receding west of Twin Peaks at 9 o'clock, and the sun made the Mission District sparkle and look Mediterranean. Closer, between Potrero Avenue and the hospital, was a lawn and flower beds. That was where she hoped the new building would fit, if voters eventually gave two-thirds approval to a construction bond.
"I'm just happy things are moving," she said to her boss. Half full.
After the call was completed she turned to a visitor. "We're going to get the money in small chunks," she said. "The main reason is people on the board, the minute they know the mayor wants something they're not going to vote for it. It's so stupid."
"You know what makes me mad?" she asked a moment later. "I do not get politics. When you get really close to it, it's awful. It's like grade school playing around. But it's with people's lives."
Every time O'Connell looked out her window she saw the Sisyphean nature of her task, some of the 90,000 San Franciscans who flock to General every year. They came in every shape and hue, but there was a disproportionate number of the limping, the lurching and the listing, the outcast and the downcast.
In an earlier conversation, O'Connell had asked: "Do you know what's the most difficult part of running this hospital? There's always a whole other population of the chronically ill who keep coming. There's always that need that's still out there."
"C'mon," she said now. "I need some caffeine."
Monday, May 8, began as most days did, with O'Connell chanting for an hour in a room set aside for her Buddhist practice in her Marin County home.
Then she drove across the Golden Gate Bridge for an orientation session for new employees at 8:10 a.m.
Her first job at General, she told them, had been as a maternal child educator. She did not state the obvious -- that now she ran the place.
"You can do just about anything here if you have the energy and ability to challenge yourself," she said.
She wasn't just whistling Dixie. The first time O'Connell had set foot in the hospital was as a patient in 1974; she couldn't afford to pay for medical care for her kids, who were 5 and 2 and needed shots. She was so poor that she didn't have the fare to take the bus to pick up her welfare check, so she and the kids walked -- a long walk. She was also in a stormy first marriage, and lived, she recalled, "with a constant fear of failure."
It was when she discovered Nichiren Buddhism, she said, that her life began to turn around. She enrolled in nursing school, and ended her marriage in 1979 when she was 32 and had her first job, at the University of California Medical Center. She was sent to General for a few months to help solve a problem. At 60, she's still there.
O'Connell worked her way up to director of education at the hospital, then ran the emergency department, and in 1991 became director of nursing, one of the most powerful jobs at General. She met her current husband, Joel Hurwitz, at the hospital where he worked in human relations.
"Because I spent so much of my life here, I get upset if somebody says something bad about San Francisco General," she said. "It's like they said something bad about Gene O'Connell. I say to myself, don't take it personally. But it is personal. I put time in here instead of with my husband and kids. To say it's not personal would be the same as to say you didn't care about it."
In 1998, O'Connell became the first woman to lead one of the premier public hospitals in the country.
"General is right up there in the pantheon with the handful of the best,"
said Larry Gage, president of the National Association of Public Hospitals. Most hospital CEOs, he said, have business degrees, or are doctors. Not O'Connell, who seems to enjoy excellent relations with the academic doctors who are her chiefs of service.
"They know I understand clinical issues, I'm not just a bureaucrat sitting here," she said. She operates on two simple principles: Patient care always comes first; and leave medical decisions to the medical practitioners.
O'Connell now has been CEO longer than any of her predecessors, and according to observers the hospital has been as fiscally sound and trouble free as an institution can be that needs an annual city supplement of about $100 million to pay for its uninsured patients, and cares for the neediest and most acutely and chronically ill, with all the attending chaos. There was a saying in her family: "You've got to hold people tight with open arms."
O'Connell gives her leadership team the freedom and autonomy she wishes she had herself. "Maybe I give people freedom because I don't have it.
Downtown decides what we need and don't need," O'Connell said, meaning Katz and the mayor and supervisors. "It's ridiculous. I should decide.
Isn't that why they hired me?"
"Because she's accomplished so much and the hospital has run smoothly for so long, Gene can afford to be so open and straightforward," said Iman Nazeeri-Simmons, director of administrative operations. "She's reached a f
-- it point in her career."
O'Connell said, "Leadership is intuitive, but you have to care about the people you're leading and care about what you're doing. My main concern is not to be a cold bureaucrat."
Walking through the hospital with her -- 3,000 people work there -- is an exercise in familiarity. She seems to know the name of virtually every employee, exchanging words or hugs, as she does with Shotsy Faust, a longtime psychiatric nurse-practitioner.
"This is her baby," Faust said. "You have to be flexible to tolerate county hospital, you have to have a sense of humor."
"Gene is humble more than anything," said Denise Rodgers, a former chief of staff at General who is now executive vice president of the University of Medicine and Dentistry of New Jersey. "She very much understands that, 'There but for the grace of God go I.' She can't be distracted. She said, 'This is what needs to happen in my life for me and my kids.' And she says, 'This is what needs to happen in this hospital for these patients."
"It's going to be a hahd day to get through," O'Connell said, but no different from most at the hospital that cost $474 million to operate last year. There would be the usual emergencies and cliff hangers. Long-overdue federal regulators from the Center for Medicaid and Medicare Services might pick today for a surprise inspection. A dozen regulatory agencies make annual inspections, most with some control over the state or federal funds that keep General afloat. About a fifth of its 2005 budget came from Medicare and about 40 percent from Medi-Cal. A new Medi-Cal payment formula promulgated by the Bush administration, and being negotiated with California, "has me very nervous," O'Connell said.
She had 35 more patients in beds than the 302 budgeted, but need trumped bureaucracy. That meant more lunch trays, more rooms to be cleaned, more hours for doctors and nurses. But such was life at a county hospital. The maintenance budget, for a 12-acre hospital with some buildings dating to 1918, equated to a paltry $1 a square foot.
"My generator's going to go at any moment," O'Connell said of the ancient piece of equipment. "We've been asking and asking to replace it for 10 years. People who have been here a long time know they have to have patience. We're always in crisis mode."
Probably her worst crisis came in April 2004 when most of the technicians in the radiology department went on sick-out over wages and antiquated equipment. "This hospital is on its knees without radiology," she said.
The city declared a state of emergency, and O'Connell met with Mayor Newsom, who pledged money for a "huge raise." But the specifics were kept secret because the deal was not final, O'Connell said. That didn't satisfy the irate technicians and their union, who were threatened with disciplinary action when they called in sick. The city later suspended the workers for five days.
Meanwhile, her son had appendicitis and was in Kaiser. She was in the Kaiser parking lot when she got a call that a union shop steward, who was opposing her in the bruising negotiations, had hanged himself.
"I knew him for years, he had a family," she said. "It was really very hard. I went from being very angry to being very depressed."
More than any other time during her tenure, the episode subjected O'Connell to harsh criticism from hospital workers. "It's probably not fair to blame individuals for his death," said Ed Kinchley, a union shop steward with 22 years as an emergency room social worker. "But in terms of the way Gene could have provided leadership, it was very lacking."
At midmorning this Monday in May, O'Connell attended a public health cabinet meeting downtown, then met with Mitch Katz. They discussed payments due to the University of California under the affiliation agreement with the city.
The university provides and pays for the doctors who teach and practice at General. The city pays everybody else and operates the hospital. The university and the city are perennially at odds over how much the university is due.
The attitude at City Hall, Katz explained, is: "The university always has money for whatever the university wants."
O'Connell agreed that the supervisors feel "they can get away with giving them nothing." Meanwhile, the university argued it was owed as much as $8 million more than the city calculated, and in addition, it knew that its affiliation contributed mightily to General's excellence and national reputation.
"And we get stuck in the middle," O'Connell said. "I hate it."
Afterward she rushed back to Potrero Avenue, where, she said, "a revolt is going on in my chaplaincy." The longtime hospital chaplain, Bob Walters, was being bad-mouthed by the hospital's newer, second chaplain, "an up-and-comer who wants to change things," O'Connell said.
Walters submitted his resignation, but O'Connell wouldn't accept it.
"I'm looking at these people," she said. "You want me to get involved in a religious war? Forget it. I won't tolerate it. Long story short, Bob's going to be staying. He's very dedicated."
There was no time for a lunch break. She had to preside over a meeting of the hospital's executive committee dealing with a "huge problem" the emergency department was having connecting its rising number of patients with primary care physicians. The committee also went into executive session to talk about three cases with, as they say in the hospital, "negative outcomes."
Afterward O'Connell asked a visitor, "Wouldn't you chant if you had my job?"
One day, a month earlier, she stood where she hoped the new hospital would be built and asked a facilities engineer how big the area was.
"I'm not sure, Gene," he said. "Between 3 and 5 acres."
"Close enough for government work," she deadpanned.
Late on May 8, Ziggy Rubel, an architect working on a preliminary plan phoned with good news. It appeared a hospital would fit in the space, which was actually 2 acres.
"Of course, your perspective as CEO," that is, someone who understood treatment needs, said Rubel, "might differ from mine as an architect. We all know who's running things, Gene." When it came to the fate of her baby, though, she wasn't in charge. Nobody really was. Not the supervisors, the mayor, the voters, the economy, the state earthquake-preparedness bureaucracy or the legislature. They all figured in the equation, however.
This summer O'Connell lost a bureaucratic struggle to have her associate administrator, Kathryn Jung, placed in overall charge of the rebuild effort. Instead, it was decided that the bricks-and-mortar people at the city Department of Public Works would direct the project, not the Health Department. Jung is to be the hospital's point person.
With so many essential questions still undecided -- where will the hospital be located? how many beds will it have? -- the bond issue is not expected to reach the ballot before June 2008. The bureaucratic hoops to be jumped through for a project of this size are worthy of Barnum & Bailey.
Typically, said Carlos Villalva, the hospital's in-house architect, big jobs take two or three years to be approved by the California Office of Statewide Planning and Development. "And you've got this debacle with the number of significant (hospital) projects all coming in at the same time.
They require a geotechnical study, looking at soil, bedrock, nearby faults, and OSPD doesn't have anybody. They send it to the Department of Mines and Geology. And guess what? There's one guy in the entire state to review this stuff. I'm not expecting any miracles."
The architecture firm of Anshen and Allen presented a preliminary plan in September for a new hospital that would extend 40 feet underground and 90 feet above. The firm predicted completion by 2015, and gave three cost estimates, ranging from $622 million to $940 million, depending on whether construction stays on schedule and how much costs escalate.
Perhaps the delays are not entirely displeasing to Mayor Newsom. When he runs for re-election in 2007, a bond issue that requires two-thirds approval to build an expensive new hospital for the poor won't be on the same ballot.
Nobody knows what would happen if the ballot measure lost. Great public hospitals in Philadelphia and elsewhere have shut forever when money ran out, or political will failed.
City Health Director Katz said it's possible some patients could be picked up by the eight nonprofit hospitals in the city, but that would pose daunting logistical and financial problems. "Especially in emergency departments where we take 50 percent of all ambulances," he said. Katz also said that the cost to the city would increase because federal programs give more money per patient to hospitals dedicated to caring for the indigent, and the city would have to make up the difference.
"Worst-case scenario," added Dr. Kevin Grumbach, chief of family and community medicine and a national authority on the medically indigent, "is we don't meet seismic standards on time and the state shuts us down. We'd be back to the survival-of-the-fittest approach for the poorest people.
"That matters to all of us, and not just because we'd like to think we're a civilized city," he continued. "It's in everybody's enlightened self-interest. Our patients are your housekeepers, your waiters, the people strung out on heroin who would otherwise be screaming at you from a median on South Van Ness."
Before she finally returned home after 9 p.m. as she does many nights, O'Connell addressed the same questions.
"It's about the survival of the hospital," she said. "The hospital won't close. It can't."
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Editor's note: A correction has been made to the above story.
E-mail Mike Weiss at firstname.lastname@example.org.