Brief history of hospital structure in America vs the CNMI

Editor’s Note: Due to its length, the following letter to the editor is being published in three sections.

Last of a three-part series

The American Hospital Association’s Center for Health Care Governance provides governance resources to over 5,000 member organizations. Their mission is to bring about excellence and accountability in hospital governance. By the way, they are governed by a board.

In the case of CHCC, the board of directors’ powers is legislated by a poorly written public law known as P.L. 16-51 rather than articles of association, which would be known as hospital bylaws. It is a misfit in the typical American hospital system as for some reason the authors of P.L. 16-51 put a governor-appointed CEO in charge of the only hospital in the CNMI, the only place that has an operating room.

In my case, the medical staff credentialing body chairman failed to uphold the rules of the hospital bylaws, even though PL 16-51 mandates that the hospital adopt the bylaws it itself wrote. The director of medical affairs failed to uphold them in the same way. The CEO likewise failed in still the same way.

Critics could say that they were justified. Critics could point to the Board of Trustees as being advisory only, even though PL 16-51 lists areas where they are fiduciary. The AG said that the Board has no authority to direct the CEO. Likewise, I submit that the CEO has no authority to direct the Board on those matters that it is fiduciary, such as physician credentialing. I ask is there ever a justification to work outside of the legal system by a government employee?

The CEO and Director of Medical Affairs have not shown up to board meeting after meeting, and refuse to be transparent to them in such matters. Again in my case, I am irrelevant. It is the process that matters. It is the American way of government “for the people and by the people”. My case is not the only case that will likely seek justice in the courts. I submit that the issue at hand is not about hospital revenue. It is about moral leadership and a reckoning, and who oversees conflicts when they arise between the medical and administrative arms of a hospital, especially, when the CEO has no prior experience as being such for any hospital anywhere.

One governor appoints one CEO and doesn’t want to change the system; what would Franklin, Morris, Adams and Washington have done with PL 16-51? Is secrecy more important than transparency within the government? Why do we have a congress and senate? Why did the CNMI join and become brothers and sisters of the United States of America. What types of freedoms should we hold true while turning a blind eye to others? What did those soldiers die for? What does your religion teach you? These are all questions that we should be asking ourselves.

Even though it is my goal here to educate the public and offer an opinion as to why I think the CHCC system will not work until its governance is corrected, I want to clearly convey that though typically management sets the tone of a corporation from the top down, this is not the case at CHCC. The nursing staff is among the best that I have seen anywhere, largely because most of them have a 4 year degree versus a typical 2 year degree on the mainland. The medical doctors are superb but many of them handle as much as 45 patients and keep their heads down. The staff in the support services and offices are likewise excellent and almost all of the above people conveyed to me that they wish for change. If they had a new strong moral leader, they would follow. I feel it in my heart.

Many modern economists believe that the hospital employed model for physicians will eventually implode. I feel strongly that the direction for the CNMI should be through diversification. For security of health care services, future added services and just plain patient controlled options, more opportunities should be opened to attract physician into private practices in the CNMI. How can this be done with the “one governor appointing one CEO model”?

Tinian and Rota should receive equal medical access and care. When I arrive in September I would like have an orthopedic schedule and x-ray facility on each of these two islands. Do you know who controls those medical care directions now, i.e. the public health department functions? All comments and criticisms are open for discussion. After all we are all brothers and sisters of this beautiful democracy. Either way, let your senators and congressmen know how you feel. Be a part of the process. Your forefathers gave a lot for you to have that right!

Grant Walker, MD
Board Certified and Spine Fellowship Trained Orthopedic Surgeon
Idaho