The health of Dayton’s heart

Sept. 09--Editor's Note: Over the next six days, the Walla Walla Union-Bulletin is taking a deep dive into something many farming communities can only dream of -- a quality health care system that's not merely surviving but thriving. Dayton General Hospital, the heart of the Columbia County Health System, is emerging as a success story at a time when many rural health providers in America are closing their doors. "A Hospital's Heart" takes a look at how this is happening.

DAYTON -- To understand where Dayton General Hospital is today is to know the recent history of Columbia County Health System, the entity that includes the small, rural hospital here, two clinics and a nursing home.

Not going back as far as 1935, when Brining Memorial Hospital was built on Dayton's East Washington Avenue and named for John Brining, the man who donated lands and funds for the cause, according to historians.

Not even back to 1964, when the present facility on South Third Street was established with a mission of providing high-quality health care for this and surrounding communities.

No, Dayton General Hospital's victory now comes after the last 20 years of struggling, Ted Paterson said in an interview last month.

In that time, this rural, critical access hospital has survived episodes of low staff morale, a rotating door of managers at the top and a bottom line that stayed firmly in the red for many years. Today, however, all of that has changed.

Paterson, who has now retired to Whidby Island, made Dayton his home for many years. He served more than one term on Columbia County Health System's board of directors, a task he found important and fulfilling, Paterson said.

But by about 2000, he said, things inside the health system became toxic.

How it began

Dayton General serves about 18 admitted patients a day. The Columbia Family Clinic, on the same campus in Dayton, sees 702 visits a month, while the Waitsburg Family Clinic, also part of CCHS, gets about 430 visits per month.

Uses of the system are a mix of town and regional residents, plus those driving through the area and winter sports fans visiting Ski Bluewood, half an hour south of town in the Blue Mountains.

The hospital has 25 beds, a 24/7 emergency department and includes Booker Rest Home, a skilled-nursing, long-term care facility.

In 2000, Charlie Button was CEO of the organization, and while Paterson thought Button knew his way around policies and paperwork, "he was not a people person ... there was not an open-door policy."

Morale throughout the hospital was down, people were leaving for jobs elsewhere and those who stayed were afraid to speak up, Paterson added.

News reports at the time showed a troubled chain of command at Dayton General Hospital. When the director of nursing resigned in June 2000, it was after months of controversy over staff management, a high number of firings (the board even passed a moratorium on firings for a short time) and low morale at both hospital and Booker Rest Home, The Times of Waitsburg reported.

More than 100 district employees, working and former, and members of the public begged the board for changes in nursing personnel treatment and management practices, The Times noted.

Meanwhile, finances appeared grim.

Assessing the problem

By 2010, the health district continued to struggle, Paterson recalled. Walla Walla-based consultant Susan Newton was hired to assess multiple issues in the health district, including personnel disagreements, rampant rumors and complaints about Button.

Newton owns Development Strategies Plus. Among other services, she helps organizations review and redesign trouble spots.

In the case of Dayton's hospital, Newton found a combination of a fervent rumor mill in town, a reluctance among employees to accept newcomers to the staff, and high employee turnover.

But everyone agreed the stability of the hospital was important to the health of Dayton, according to reports in The Times.

In recalling that time, Newton recently told the Union-Bulletin she could not discuss specifics of the report commissioned by the health system's board of directors but that Dayton is like any small town.

"Everyone feels entitled to have and to share an opinion," she said.

In the end, Newton said, the board eagerly accepted the information she'd gathered and presented.

"They wanted to understand what was actually happening," she said. "I think they were willing to listen."

Newton's work was invaluable to an organization that lacked a true human resources department, and for its employees who feared getting fired over any complaints, said Paterson, who was on the board then.

At the same time, Button was hamstrung by the town's perception of the daily doings inside Dayton General.

By about 2012, a new interim CEO was in the picture and creating a much more professional workplace, Paterson said.

"John Smiley brought structure back and, pretty much, laid the groundwork," Paterson said.

Healing the hospital

Smiley instituted a number of positive changes, including establishing a human resource department and opening channels of communication between employees and their direct supervisors, Paterson recalled.

And he began mentoring Shane McGuire, who had been chief operating officer of Dayton General since 2010. McGuire, who was working in a similar position with an internet provider company in Walla Walla when he was hired to join the Columbia County Health System, took on management of the health system's internet technology, laboratory, facilities, dietary and pharmacy departments.

Smiley understood McGuire's potential early on, Paterson said.

"Smiley mentored McGuire in terms of being more than an IT person. He said, 'You need to be looking at this overall -- the accounts, construction, services,'" according to Paterson. "Shane, as an IT and techie, was not a people person at the time. He became one."

In December 2015, the board of directors chose McGuire over two other candidates to become CEO of Columbia County Health System.

Wes Leid, on the board then and now, doesn't mind saying he didn't vote for McGuire as CEO.

At the time, the hospital was still a difficult place to work, Leid said.

"If you would have talked to me five years ago about what it was like, I think you would have seen frowns," he said. "No one talked to each other."

Now Leid is not sure where Dayton General would be without McGuire at the head, he said.

"He's really impressed me. I think the world of him. He works hard and he has good ideas," Leid said.

Underestimating the system

McGuire had already grasped the most important facets of care in Columbia County by the time he took over Smiley's office, Paterson said, an opinion seconded by Leid and current board President Bob Hutchens.

"He recognized Booker (Rest Home) was an important piece to the community," Paterson noted. "You see a lot of gray heads in Dayton, and the idea is to keep them in the community and with their families."

As well, people were driving past Dayton General daily, on their way to Walla Walla or Tri-Cities for medical treatment.

Adding that to staff unrest and difficulty in recruiting providers, it was easy to see why Dayton, Waitsburg and other residents underestimated what the health system could provide, Paterson said.

There was more. Take patient billing. Bills were going out late, hampering the hospital's ability to make payroll and pay vendors, Hutchens and Paterson said.

Medicare and Medicaid, which make up a significant percentage of insurance coverage for users of the health system, are complex and difficult to navigate.

The instructions for submitting billing to those entities is 300 pages long, Hutchens said.

"And there are going to be mistakes," he said. "If the bill gets 'caught' in the computer, it puts it on hold, and it's reconsidered."

Paterson said it became easier to outsource billing after stacks of accounts receivable files had piled on desks, awaiting attention.

"I think the logic became like cherry picking -- take the easy ones, ignore the hard ones, so then you just write them off. That became a board issue, how much we were writing off," Paterson recalled. "It became a real balancing act."

The board was writing off hundreds of thousands of dollars in receivables each year -- patient bills they didn't expect to every see payment on.

Medicaid reimbursement is a burden for every medical entity, Paterson said, explaining that the federal health insurance pays "the very bare minimum."

"We're getting about $90 a day, and the care cost $146 a day," he said.

Choices and change

McGuire and others had to look at what services could be provided to patients to offset that loss, Paterson said.

McGuire has worked hard to get the right people in the right positions, which Hutchens attributes to getting things like staffing, billing and services back to a healthy state.

"Recruiting people to a small hospital district is nothing but challenging. In a small district like this, leadership is critical. Our district has suffered from turnover at the top ... you need consistency," he said. "Not everyone wants to live in a town with a population of 2,500. And we can't pay as much as a big hospital."

That's the nature of a critical-access hospital, he added.

"It's not designed to make a lot of money," he said. "If you have a good year, Uncle Sam takes back a percentage."

McGuire's skill in landing talent to handle those and more challenges made the next step slightly easier -- asking property owners within the hospital district to support a $5.5 million renovation in 2014.

The need for change was obvious to many eyes. The hospital needed a substantial overhaul to improve acute care, lab, radiology and other services to create better care and to take advantage of about $350,000 in federal money, officials said then.

"When the hospital was first built, health care was vastly different," McGuire pointed out an a recent tour of the Dayton campus. "People spent a lot more time in hospital beds. Now it's a lot more outpatient services, but we're still an inpatient facility."

The board voted to put the redesign bond on the ballot for that year's general election in November, asking at least 60 percent of property owners to say yes to a price tag of about 50 cents per $1,000 of assessed property values.

"The community almost didn't vote for it," Hutchens recalled. "It was an incredibly slim margin."

In the end, absentee ballots from Waitsburg voters pushed the bond to a squeaking victory at 60.4 percent, he said.

Hope for a community

Construction began in July 2016, with plans for five building phases. Projects included adding an aquatic therapy pool, plus new or redesigned areas for pharmacy, acute nursing station, laboratory -- 92 percent of the labs needed for patients are done in-house, around the clock -- imaging, emergency department waiting area and more. Plus a relocated main entrance, McGuire pointed out.

The project finished up earlier this year with a $5.8 million tab, which included elements not in the original scope, but that presented a great opportunity for Dayton General Hospital to add value to the facility and the community: a hyperbaric wound care treatment space and replacing water lines for both Booker Rest Home and the main hospital.

Columbia Rural Electric Association assisted with the cost overrun from its community fund, McGuire said.

And the renovation enhanced privacy and security. One notable bonus comes from placing the emergency department entrance in the front of the facility, "rather than hidden in the back of the facility is a big plus for people from out of town seeking emergency care," McGuire said.

As well, Dayton General Hospital's wound care center, including hyperbaric treatment, is big for the area, the CEO said, noting the next closest treatment options are in Richland and Clarkston.

One of the biggest benefits to ripping the building apart and reworking it is not as publicly visible, McGuire said.

"Efficiency and layout of the new spaces is helping us treat more patients while also improving patient safety through monitoring and unified nurse call systems," he said.

Giving credit

While he is quick and robust in praise of people in Dayton and Waitsburg who pushed for a better system of care, McGuire does not deny the hospital needed new leadership in the top tiers, given the turnovers and loss of trust among employees before he took the helm.

"It is tough to execute strategically and build culture when you have interim candidates," he said. "I believe that confidence in the services we were providing had suffered, that staff morale was affected by it as well, and that we lost some of relationship we had enjoyed with our communities."

Added up, those issues ultimately put pressure on the hospital's bottom financial line, he added.

Rural health care is always going to be challenging, but Dayton's situation is more sun than the shadow of years past.

"I feel that our health system has positioned itself better over the last couple of years," McGuire said. "We have increased volumes across all service lines, we have increased census through partnerships with our larger area health systems, and we have been able to add service lines that appeal to both local and regional residents."

Staff, he added, is excited and motivated, seeking to be worthy of the support the community has shown.

With Walla Walla General Hospital closed and Providence St. Mary Medical Center running at high capacity, Dayton General Hospital stands on the brink of making a medical difference for families there. Services have been tailored to residents and those who come to the area for recreation or on their way elsewhere.

There's more to do, McGuire noted, including pushing health care outside the hospital and clinics in programs like palliative care and home health.

"We are looking hard at what it means to age in our community, given that we will be the fourth oldest county in the state by 2030 if our demographic trends continue to maintain ... We feel that our community needs robust home care options, assisted living, adult family living, and memory care options."

McGuire seems confident it can all be brought to fruition. "We are very nimble. And we are a health system, and that's really community-based care. There is nothing more satisfying than making a difference."

Sheila Hagar can be reached at [email protected] or 526-8322.

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