VA Gets it Right in Marion, Illinois, Hospital Case

The government doesn't all the time do the right thing. But a tip of the stethoscope goes to the Veterans Administration. Dr. Michael Kussman, U.S. veterans affairs undersecretary for health, seems to know what he is doing when it comes to communicating out of a serious crisis -- or maybe he knows how to take advice given behind the scenes. Whichever, way to go VA!

The VA is linking 19 deaths in the past two years to poor health care at the veterans' hospital in Marion, Illinois. (See http://www.usatoday.com/news/nation/2008-01-28-illinois-hospitaldeaths_N.htm for details.) According to USA Today, "The hospital undertook many surgeries that its staffing or lack of proper surgical expertise made it ill-equipped to handle, and hospital administrators were too slow to respond once problems surfaced," according to Dr. Kussman (emphasis added).

It's a little late, but the VA investigated thoroughly and here are some appropriate actions and statements that make the agency worthy of compliment:

• I love Dr. Kussman's quote. "I can't tell you how angry we all are and how frustrated we all are. Nothing angers me more than when we don't do the right thing." He accepts responsibility for overlooking a serious problem and expresses agency and personal outrage. He added another good point later when emphasizing that what happened in Marion isn't at all typical of other VA hospitals.
• The VA will help victims' families file claims under the VA's disability compensation program. The agency isn't sitting back. It's helping alleviate the burden on these families. For a 180-degree-different approach, see the Sierra Pre-Filled thread elsewhere in this blog.
• The hospital suspended inpatient surgeries in August when problems first came to light, and Dr. Kussman said they'll remain suspended indefinitely. Good for you! Make sure the problem is fixed and you can credibly assure patients that what happened before can't happen again. If you work at a production facility, don't be in a hurry to come back on line after a crisis shuts you down. Take a small financial hit now instead of a potentially large hit later. Get it right.
• The VA started an administrative investigatory board to review care at the hospital and follow up on issues and concerns raised by employees. That's a great move! If the hospital had heeded the employees' caution flags, which almost always are waved before a problem goes crashing into the rail, it might have averted the crisis and, more important, saved some lives. Listen to employees. Take their concerns seriously. No one knows your organization's weak spots better than the employees working in the pit.
• Last September, the VA responded quickly to the crisis by replacing the Marion VA's director, chief of staff, chief of surgery and an anesthesiologist. Kussman assured, "The previous leadership will not return (to their former jobs)." In addition, hospital officials apparently didn't bother checking the references of one of the key surgeons whose skills are suspect. According to USA Today, "The Marion VA hired (the surgeon) in January 2006 after he practiced in Massachusetts, where he was under investigation for substandard care in 2004 and 2005. The claims include allegations that he botched seven cases, two ending in deaths." That's information that shouldn't have been too hard for HR to uncover.
• Spokespersons with the Marion VA referred reporters' calls to the agency's headquarters in Washington. That means the VA was still answering the phone in Marion instead of hiding. And it means the national VA is controlling the flow of official information to ensure a single consistent response to reporters.

If you want a good example of how not to deal with a smoldering crisis, may the item posted below be a reminder to you.

This May Be the World's Record for Duration and Cost of a Smoldering Crisis

Today's Courier-Journal in Louisville, Kentucky, published one more in a seemingly endless series of stories about class action suits and the Catholic Church. This one involves the Catholic Diocese of Covington in Northern Kentucky. (http://www.courier-journal.com/apps/pbcs.dll/article?AID=2008801290398) Two special masters in the case reviewed claims from 400 people: they approved 243 and rejected 157, with 100 of those being appealed to a judge. They awarded $62.9 million to victims abused since the 1950s in 57 Kentucky counties. The article goes on to give some perspective to the size of the award. The Boston Archdiocese, fourth largest in the country with 2.2 million parishioners, settled two of the largest cases in 2002 and 2003 for $95 million. Covington has just 89,000 parishioners with a settlement about two-thirds as big as Boston's.

My point is that documented cases of sexual abuse by Catholic clergy date back at least a generation and almost certainly long before that. We've all read more cases than we would like to have read about leadership in the Catholic Church ignoring the atrocities, moving perpetrators to new locations instead of out the door, and in general simply looking the other way.

At times I can't imagine so much bad judgement being repeated so often until until I read another of the many accounts of businesses doing the same thing. I could refer you to Firestone ATX tires, known by some insiders to be defective, who did nothing for seven years until 271 people were killed in accidents caused by blowouts. Thirty class action lawsuits were filed. Or it might be WellPoint Inc. in Indianapolis, who had to react quickly when its CFO, David Colby, was caught involved in more than 30 affairs in the last half of 2007 alone. WellPoint wisely didn't ignore that smoldering crisis and sent Colby on his lecherous way.

When you suspect a smoldering crisis in your midst, take swift and immediate action. Let the Catholic Church and its failure to respond for many decades -- and the consequences of being caught -- be always on your mind.

Perception Is the Same as Truth When It Comes To a Crisis

You don't have to have a crisis to have a crisis. If the public perceives some sort of wrongdoing, you have a crisis whether you're guilty or innocent. No matter how cautious an organization may be, stuff happens.

I read an interesting piece on the blog of Jim Bruggers, environmental reporter for The Courier-Journal in Louisville. (http://www.courier-journal.com/blogs/bruggers/blog.html) He refers readers to an AP article (http://ap.google.com/article/ALeqM5juSZjdR1i2xIc8nWrDrNyRjHFtSQD8U8DNF80) about the West Virginia Supreme Court Justice who removed himself from a pending case involving Massey Energy Co. Pictures surfaced of Chief Justice Elliott "Spike" Maynard and Massey Energy CEO Don Blankenship on vacation together in Monaco in 2006. Both men claim they traveled there separately at their own expense, and being there at the same time was a coincidence. Maynard says his friendship with Blankenship hasn't affected his partiality on the bench. But he removed himself anyway, saying, "it has now become an issue of public perception and public confidence in the courts." Ya really think so?

Wait. I haven't gotten to the juicy part of the story. Maynard was part of a 3-2 majority in November that overturned a multi-million-dollar judgment against Massey Energy that Harman Mining had won in a contract dispute. With interest, the decision is worth $76.3 million. The lawyer for Hugh Caperton, president of Harman Mining, suggests Maynard's vote be withdrawn from the judgement, leaving a 2-2 tie that would go down in favor of Caperton. The lawyer for Massey Energy called that suggestion "absurd." The court is scheduled to hear the reconsideration motion on January 24. It must appoint a replacement for Maynard. That's not easy and clear-cut either because of who knows whom, but I'll let you read the details yourself if you care to.

If you're keeping score, that's one personal crisis for the chief justice, one crisis for the West Virginia Supreme Court, and probably two crises for Massey Energy. Of course I'm in no position to say who's right and who's wrong in this tangled web. My point is that you can experience a crisis without doing anything wrong as long as your stakeholders perceive something to look a little shady.

The Plot Thickens for Sierra Pre-Filled

I've been following the apparent demise of a company called Sierra Pre-Filled and have posted several notes here about it. This is the North Carolina company that had to recall heparin-filled syringes for cancer patients due to a bacterial infection. No spokesperson nor the company president have been out front controlling this crisis, making statements, or showing compassion for the victims who become violently ill. It appears the company's web site has been taken down and no one I can find in the media has checked on whether the company is still operating or if it has done anything to prevent a recurrence. Several legal firms are circling the waters contacting victims. This is going to be expensive and may be exacerbated by the company's lack of leadership -- or even lack of a public presence. From what I can tell, the company has even pulled the plug on its web site.

The recall has now been expanded. Apparently, some of the contaminated syringes were distributed under another company's name, B. Braun of eastern Pennsylvania. FDA now says it's not just heparin syringes, but plain saline syringes that may be contaminated.

People, a slow response or no response just makes things worse when your organization is in crisis. Have a plan. Review and practice it periodically. And use it when you have to.

Schools Must Be Prepared Even for the Unlikely and the Unthinkable

This is a story that should cause schools to reassess their security and make sure their crisis plans are up to date. In Lewisville, Texas, a magician made an elementary school student disappear -- and no one at the school even missed her. If you want the whole story from the Dallas Morning News, see http://www6.lexisnexis.com/publisher/EndUser?Action=UserDisplayFullDocument&orgId=574&topicId=100020825&docId=l:730399794&start=4.

Here's what happened. A 22-year-old professional magician, who performed regularly at Creekside Elementary, a school which he used to attend, was able to walk out the door with a nine-year-old fourth-grade girl on January 18. Praise God he returned her an hour later, but not before apparently attempting to have her perform sexual acts and photographing her.

"How in the world does someone abscond with my daughter and she's not missed?" the girl's father wants to know. "How is it that an evil predator is allowed to roam freely inside of our public school? How does that happen?"

Lewisville school spokeswoman Karen Permetti doesn't know the answer to that yet. "The district is reviewing procedures to ensure that such an event cannot happen again," she said in a written statement issued yesterday. That should be a relief to parents!

In a letter to Creekside parents, Principal Steve Polzer said that the magician, Daniel Catarino Reyes, made an unscheduled visit to the campus Wednesday to see former teachers. "The visitor was a familiar man to staff and students because of his annual end-of-the-year magic show," the letter stated. Reyes had no criminal record. He was arrested and released on $200,000 bail this week.

School officials can't be too careful. They need to have plans and procedures in place to prevent even well-know school visitors from harming children. Here in Louisville, Kentucky, the Jefferson County Public Schools have a program called Every1Reads, which uses thousands of volunteers to read with children in school. It's an excellent program, one that I participated in. But there's no way the school where I read could have prevented me from walking out a side door to the parking lot with a child who trusted me.

According to the Morning News story, Deputy Chief Gary Hodges of the Dallas school district police said,"It's really hard to control the way somebody leaves a building. In terms of fire codes, you can't lock doors and prohibit or inhibit access from the inside."

If you work at a school, you should look for ways to make your building more secure, even against "friends." If you're a parent, you should be asking your kids' school how they would prevent an abduction like this one. And if you are a school communicator, you should be prepared to deal with your many audiences should an incident like this occur in your school district.

Despite the occasional story like this one, keep in mind that far more children are hurt and abused in the home than in school. Schools are in general much safer than homes. Nevertheless, schools owe it to families who depend on them to be as secure as possible. And then even more secure after that.

Be Sure To Have a Complete Pandemic Plan in Place

Remember the avian flu? We heard a lot about it last winter, but the media's attention turned to other news by the time summer arrived. The attention waned, but the avian flu didn't. Of 86 confirmed human cases last year, 58 of those people died. Since 1994, the numbers are 349 and 216, respectively (a 62% mortality rate). The Institute for Crisis Management continues to advise clients and anyone else who will listen that having a plan in place to deal with a pandemic is essential. So, too, does the World Health Organization (WHO). This is from WHO's web site (http://www.who.int/csr/disease/avian_influenza/avian_faqs/en/index.html#control):

"During past pandemics, attack rates reached 25-35% of the total population. Under the best circumstances, assuming that the new virus causes mild disease, the world could still experience an estimated 2 million to 7.4 million deaths (projected from data obtained during the 1957 pandemic). Projections for a more virulent virus are much higher. The 1918 pandemic, which was exceptional, killed at least 40 million people. In the USA, the mortality rate during that pandemic was around 2.5%.

"Pandemics can cause large surges in the numbers of people requiring or seeking medical or hospital treatment, temporarily overwhelming health services. High rates of worker absenteeism can also interrupt other essential services, such as law enforcement, transportation, and communications. Because populations will be fully susceptible to an H5N1-like virus, rates of illness could peak fairly rapidly within a given community. This means that local social and economic disruptions may be temporary. They may, however, be amplified in today’s closely interrelated and interdependent systems of trade and commerce."

So far, the virus hasn't mutated to a form that can be passed from human to human. Those who have contracted avian flu did so through close contact with infected birds or feces. But each case of human infection, according to WHO, increases the chance that the virus will mutate into a contagious strain.

So what does the flu have to do with your business? Plenty. You should plan for a pandemic just as you should plan for a fire or a class action lawsuit. You need to consider human resources policies, supply chain disruptions, cash flow interruptions, legal problems, and communications challenges. Consider the 1918 Spanish Flu:

"Entire families became ill. In Philadelphia, a city especially hard hit, so many children were orphaned that the Bureau of Child Hygiene found itself overwhelmed and unable to care for them.

"As the disease spread, schools and businesses emptied. Telegraph and telephone services collapsed as operators took to their beds. Garbage went uncollected as garbage men reported sick. The mail piled up as postal carriers failed to come to work.

"As the bodies accumulated, funeral parlors ran out of caskets and bodies went uncollected in morgues." (http://1918.pandemicflu.gov/the_pandemic/01.htm)

Does your pandemic plan prepare your organization to deal with a shortage of employees, lack of transportation for supplies and end products, and even no phones or electricity? This may sound extreme, but you're better off preparing for the worst than not preparing at all.

If you need some help with your contingency planning, check out the Institute for Crisis Management at http://www.crisisexperts.com/.

Is This Any Way to Run a Railroad?

I have been critical of the rail companies as a community relations professional in the chemical industry. It's tough to get railroad folks who can answer tough questions to speak at the two industry-related community advisory committees that I facilitate. We get a lot of questions from the community about security of rail yards, why cars sit near neighborhoods for days, why trains stop and block traffic at crossings, who should fix the rough road crossings, and so on. Plus, the chemical companies often take the blame for accidents involving their materials, even though the railroad has legal responsibility and accountability.

So I was interested to come across this item from The Courier-Journal web site (Louisville). http://www.courier-journal.com/apps/pbcs.dll/article?AID=/20080104/BUSINESS/80104016. A huge crash and fire involving a train in Brooks, Kentucky, last January derailed about 25 cars. Some were carrying hazardous materials that caught fire. Firefighters fought the blaze for days. As a result of that accident, the Federal Railroad Administration conducted safety checks across CSX rail lines in 23 states. FRA has announced a $350,000 fine, claiming that "CSX failed to replace defective rails, didn’t make track repairs where problems already were known, hauled tank cars with loose closures and without proper shipping papers, and did not properly perform or record brake tests."

To its credit, CSX appears to be taking the high road and not excusing away its behavior. In a release, the company stated, "CSXT appreciates the important work performed by the FRA and was pleased to cooperate fully with the effort. CSXT is committed to continuing its strong safety improvements through prudent, long-term investments in infrastructure and technology, as well as through diligent inspections and training."

When you're caught with your pants down, as CSX was, there's not much else to say. But some companies will have excuses or dispute inspectors' findings. CSX chose to swallow crow and live to fight another day. If only they did a better job filling requests for speakers!

A postscript: The CSX web site invites the public to call if there's a train stopped at a crossing, an object on the tracks, malfunctioning crossing equipment, and more. (http://www.csx.com/?fuseaction=general.tellcsx) I added the number into my cell phone contacts. I want to see what will happen if I call. That number is CSX's Public Safety Coordination Center at 1-800-232-0144.