Residents of Anderson Valley:
For those of you who don’t know me, my name is Eric Arbanovella. My wife Cindy works as a Nurse Practitioner at the Anderson Valley Health Center (AVHC). I am a stay-at-home dad and a volunteer driver with the Anderson Valley Ambulance Service. Previously, I was a software engineer and manager.
Cindy and I are firm believers in the essential role AVHC should play here. However, since Judith Dolan retired as AVHC’s full-time executive director in 2011, the AVHC board of directors has hired three part-time executives to manage the clinic: Diane Agee, executive director; Dave Turner, CFO; and Lucresha Renteria, Chief Operations Officer. Under this management, critical systemic problems at AVHC have reached a stage where continued inaction will cause the clinic to either fail outright or cease being able to provide acceptable patient care.
I wrote a confidential letter discussing these problems to each of the AVHC board members on March 28, 2014. I have received only a polite but noncommittal response from the board.
I have no choice but to make public my discussion of six serious systemic problems the clinic faces. I ask for your assistance in making this information known to our community.
What’s Broken at AVHC
1. Inadequate hiring practices
Since Dr. Jack Power’s retirement several years ago, AVHC has had only one medical doctor on staff, Dr. Mark Apfel. Despite this, AVHC has not hired a single general practice doctor to work at AVHC despite expanding clinic hours and responsibilities. With Dr. Apfel’s increasing age and continued depth of involvement with AVHC, it must be obvious to all parties concerned that AVHC needs an additional staff physician. Without another staff physician, AVHC faces a crisis once Dr. Apfel retires.
Cindy is now sole provider at least half of the day on Tuesdays and Wednesdays, and she often works alone when Dr. Apfel is away. Without a medical doctor on-site, AVHC patients that require critical advanced care have no choice but to wait for the ambulance or risk personal transport to Ukiah or the coast. This increases strain on the volunteer Anderson Valley Ambulance Service and significantly degrades the health of the Valley.
Hiring Shannon Spiller as a Physician Assistant improved patient care somewhat. But when the clinic’s long-time RNs (Judy Nelson and Anjes de Ryck) retired last year, AVHC administration appeared not to have prepared to hire replacements, thus leaving the Health Center without a permanent RN for 6 months. This dramatically increased all providers’ workloads as their responsibilities expanded to include filling all medications, storing medication orders, administering medications outside the Medical Assistants’ scope of practice, contacting patients over the phone, triaging incoming patients, and handling a variety of tasks best suited to RNs.
Combined, these facts indicate that AVHC management is unable to perform one of its crucial functions, namely hiring providers and sufficient support staff.
2. Inadequate communication with community and staff
As Gene Herr’s message to the board earlier this year pointed out, the promises that AVHC management has made to provide articles of incorporation, operating bylaws, financial statements, budgets, board agendas, or board meeting records to the community have gone unfulfilled. The only significant AVHC community outreach to my knowledge are the terse pieces written on behalf of the board printed in the Anderson Valley Advertiser last year, which raised far more questions than they answered.
This lack of communication extends inside AVHC as well. Cindy has had no HR reviews or annual performance reviews since starting at AVHC in 2007, nor is she aware of any extant functional review process. Staff meetings have almost entirely ceased. Management decisions are only discovered well after the fact and often appear not to be based on the recommendations of the full-time staff providing patient care.
3. Broken IT system
AVHC is now critically dependent upon its computers for all day-to-day operations. Despite this, AVHC's IT system has repeatedly and regularly failed due to the apparent inability of AVHC management to secure reliable and timely support for AVHC’s computers. Significant IT problems have included periodic failure of the entire computer system; failure of individual staff machines, charting computers, printers, and vital sign station computers; and inability to correctly configure and deploy machines.
The most egregious example of this occurred when PG&E scheduled and reported a significant weekend power outage weeks in advance. Despite this warning, staff returned to AVHC on Monday to find the computer system completely dead. For most of that Monday the Health Center was barely able to function, all because no one involved had the foresight to plan for the outage by turning off computers in advance.
As with expanding the Health Center building on the cusp of a bad recession, switching over to an computerized clinical system without a functional plan for how to keep the computers working is probably another example of short-sighted decision making based on grant availability. However, unlike having too much unoccupied space in the AVHC building, the precarious nature of AVHC’s IT system seriously undermines the care AVHC provides to the community.
4. Zero admin time for providers
It is common practice at both private and public clinics to block off small daily periods on medical provider schedules to allow providers to complete and follow up patient care. This is time to examine lab results, contact other health care providers, consult references and current research for complex conditions, review and revise patient charts, and most importantly, return phone calls to patients. These activities are fundamental to basic patient care and require paid time from the provider during working hours.
Until the last week, providers at AVHC had no time scheduled to perform these activities during the business day. The consequence is obvious: these things often aren’t done, and patient care suffers. Providers have to find other time outside business hours to complete this work when possible.
5. Negligible day-to-day management
As with any business, daily events within the Health Center require prompt, direct responses for the clinic to function. This is the job of a clinic manager. Dr. Apfel and the other medical providers cannot do this job, as they are focused on patient care. The nursing staff cannot do this, as they are overwhelmed supporting the medical providers. The front office staff cannot do this, as they both have basic patient contact and record-keeping responsibilities and also lack the necessary scope to take executive action. AVHC’s three part-time executives, all split between at least three clinics in the county, are not there most of the time.
As such, it is not an exaggeration to say that no one is actually running the Health Center on a day-to-day basis. I would say that AVHC is blessed with staff who know how to work beyond their job descriptions and are able to function independently. But it is only a matter of time before lack of oversight has extremely bad consequences for AVHC.
6. Kathy Corral’s termination
Finally, I would like to reassert that no adequate explanation has ever been given for the reasons behind Kathy Corral’s abrupt termination last year. The year before she was terminated as Dental Manager, Kathy proposed a long list of cost-saving measures the dental office could take to handle reduced dental income from the federal grant’s required sliding fee scale for dental work. That list included the offer to reduce Kathy’s hours by 20%. While Kathy completed all the items on that list that were under her control, the critical suggestions that required administrative action were apparently ignored, as were Kathy’s repeated requests for financial reports. Moreover, no indication has ever been given to Kathy or to the public that federal grant funds were being used as intended to help offset reduced dental income.
What’s more, the way in which Kathy was terminated was downright despicable. I believe some characterized the firing as corporate. A rational corporation would have gone to some lengths to preserve what knowledge Kathy had about her role, the dental office, and the community before letting her go, even if it had solid grounds to support termination. To my knowledge, AVHC did exactly nothing to preserve any of Kathy’s knowledge. As such, a better description of her termination would be sub-corporate.
As no adequate explanation has been offered to the community, the only conclusion I can draw from the available facts is that AVHC management did nothing about dental finances until it was far too late for anything other than unnecessarily drastic measures. If that is the case, that alone seems proof of executive incompetence both in the reasoning behind and manner of Kathy’s termination.
In conclusion, I apologize for the length of this letter, thank you for your consideration, and ask you to forward this to others who may be interested.
In my opinion, the board must hire a full-time, capable, and preferably local manager who consults medical providers when making critical decisions about their practice. Regardless, it is crucial for our community to discuss the future of AVHC.
The next board meeting is at 5:30 PM on Monday, May 19, 2014, at AVHC. The board has emphasized to me that communication with the community is something they need to improve. We can do our part by attending the meeting, speaking up, and holding the board accountable for the ongoing problems at AVHC. Please try to come if you can.
If you are unable to attend, consider writing the AVHC board (care of AVHC: PO Box 338, Boonville, CA 95415) demanding that they act to correct these problems immediately.
Otherwise, unless we act soon, AVHC is destined to fail.