Tuesday, November 28, 2017

CHI Franciscan Harrison to Close, So Where Do We Go From Here?

Last week, the final decision was handed down by the State Department of Health on the CHI Harrison Certificate of Need application.  Closure of the CHI Harrison Bremerton facility and relocation to Silverdale will be proceeding as planned.  Some Kitsap residents are discouraged at the thought of losing our beloved hospital in the City of Bremerton while others are thrilled at the prospect of having access to advanced technologies at the new, state-of-the-art facility in Silverdale.  

So where do we go from here?  First, we need to put our differences aside and reflect upon the core values which ignited the spirited CHI hospital debate in the first place.  Everyone in Kitsap County needs access to affordable, high quality healthcare because we will all be patients eventually.  We need a representative voice on health care matters to speak for the community.  The mission of this formalized group, known as a Community Oversight Board (COB), would be to work in collaboration with CHI Harrison leadership to draft a community benefits agreement (CBA.) 

Having a COB is critical for Kitsap County to improve the health of our community.  Non-profit hospitals are required to provide tangible community benefits to in order to qualify for tax-exempt status.  Lack of transparency on behalf of non-profits and subjective calculation methods regarding “uncompensated care” led to increased oversight by the IRS and Congress.  Out of 2900 hospitals nationwide, 60% are tax-exempt; these exemptions are worth $12.6 billion annually. Including the Bremerton and Silverdale locations, CHI Harrison received a combined property tax exemption totaling $1.63 million dollars in 2016.    

In 2010, the Patient Protection and Accountable Care Act (ACA) amended the IRS code to regulate tax-exempt hospitals more closely.  They are required to conduct community health needs assessments every three years (here is the CHI Harrison survey), develop improvement strategies, and implement consumer protections on financial assistance, billing, and collections practices.  Additionally, Section 9007 of the ACA requires annual reports by the Secretary of the Treasury to Congress on four categories of community benefit involving tax-exempt hospitals:  charity care, bad debt, unreimbursed costs for services of government programs, and the costs of community benefit activities. 

This concept of community benefit is vital, going beyond improvements in health – ensuring effective use of scarce resources, enhanced accountability of hospital leadership, and building the capacity to address health care issues. Increasing community engagement does not appear to be a high priority for all non-profit hospitals.  One study examined governance structure at 14 of the 15 largest non-profit hospital systems in the nation, 8 of which are controlled by Roman Catholic organizations. 100% of those hospitals had oversight for financial compliance measures, while only three of eight Catholic hospital systems had established a committee to oversee community benefit policies and programs.

In Kitsap, a COB would serve as an established platform for collaborating with CHI Harrison leadership while holding the parent corporation accountable for meeting the healthcare needs of our community by improving our health, quality of life, and even community vitality.  This entity could include hospital administrators, elected officials, health care workers, and interested community members.  Ideally, representatives from CHI leadership and the Harrison Hospital Board would be at the table, as should elected officials including City Council members and possibly, a Kitsap County Commissioner.   Involvement on behalf of police, fire, and EMS personnel would be critical, as would utilizing the expertise of healthcare workers from a variety of disciplines and backgrounds.  Finally, interested community members who see access, affordability, and choice as high priorities are vital to the long-term success of this endeavor.

While improving the health of our community can sometimes feel like trying to move mountains, Kitsap County residents undeniably need a representative voice on health care matters.  Confucius said, “the man who moves a mountain begins by carrying away small stones.”  It is time to lay the groundwork for Kitsap residents to formally engage in meaningful dialogue with leaders of our local hospital corporation, whether operated by CHI Franciscan, Dignity Health, or a still-to-be-named corporate entity. 

Please fill out the CHI Harrison community benefits survey linked above and do not miss this novel opportunity to influence health care in our community.  Together, we can have a representative voice and we should use it to hold the non-profit corporation operating our community hospital accountable for making decisions that are unquestionably in the best interest of our people in this constantly evolving healthcare landscape.  

Tuesday, November 21, 2017

A Thanksgiving To Remember

As we come upon the holiday season, it seemed appropriate to tell a Thanksgiving story from a few years ago.   Our family spent the day playing board games, watching a little football and taking a long walk.  After an early supper at my parents’ house, we returned home and started our typical evening routine -- baths, bedtime stories, and snuggles; the night was mundane until well, it wasn’t.  

Having four young children within a four-year span meant chaos had become ever-present in our lives and yet, this evening was almost serene by comparison.  The children were not screaming and yelling, jumping off the furniture, or tackling each other.  There were no unforeseen accidents or injuries, like a child falling and cracking their head open on the toilet after getting out of the bathtub.  While our house never seems ready for entertaining surprise visitors, this night was as good as any for unanticipated events.  

The older two were already dressed for bed, my husband was bathing the baby, and I was putting away clean laundry when there was a knock at the door.  After descending the stairs, I opened the door to face two police officers.  My surprise was likely evident.  “Happy Thanksgiving officers.  What brings you to my front door on Thanksgiving?”  I secretly hoped their visit was part of a new outreach program, but it was not.  They informed me there had been a 9-1-1 call from our house fifteen minutes ago followed by a hang up and they were obligated to respond because someone might be in trouble.

Someone was DEFINITELY in trouble, I thought to myself.  When a parent is uncertain, my advice is to simply pause and take a few deep breaths.  This not only gives us a moment to think before we act, but it also allows the perpetrator to give themselves away unintentionally, which may guide our next move.  The boys were old enough to know better and our youngest child was 2, which left my three-year-old daughter as the most likely culprit.  Getting undressed for a bath, she poked her little head out the door of her bedroom to say “hello” with a big grin and a wave. She looked pleased with herself, but maybe a little too pleased. 

There needed to be a lesson in all this, so I asked the officers into our foyer to have a few words with my children.  I threw a bathrobe on my daughter and the three boys came to sit on the stairs for this brief educational opportunity.  The officers reviewed the when and why for calling the emergency number.  My children nodded in understanding, though my daughter still had a sheepish grin. 

As the officers turned to leave, they reminded us they always check homes when hang-ups occur and if it happens frequently, there will be fines attached to not controlling our little ones better.  My husband and I are still unsure of where she learned about dialing 9-1-1 for emergencies.  It could have been at pre-school, a family movie, or even overheard in public. As she has gotten older, I have realized she rarely misses the details of anything.  It is a valued quality except when in combination with the impulsivity of a three-year-old. 

While there have been no more 9-1-1 calls and unexpected visits from police officers, this experience is another one of those parenting life lessons. Most of all, I am thankful the deputies “dropped by” when the scene was calm.  If they were on my doorstep on any other regular evening, things might have turned out differently.  I wish all of you a Happy Thanksgiving, and may you enjoy a day free of a surprise visit from your local Sheriffs’ deputies. 

Tuesday, November 14, 2017

A Tear and A Smile: A Eulogy for My Father

My father was my mentor, friend, business partner, and stalwart supporter throughout my life.  He was a phenomenal physician who will be dearly missed by all who knew him.

Below is the eulogy given at his Celebration of Life on November 11, 2017.  

My father was not religious in the traditional sense, so rather than quoting from scripture, it seemed best to look for a passage which epitomized the man he was.  If you knew him well, you will understand why I chose the poem, “A Tear and a Smile,” by Khalil Gibran, an Arabic Christian poet. 

I would not exchange the sorrows of my heart, for the joys of the multitude.
And I would not have the tears that sadness makes to flow from my every part turn into laughter.

I would that my life remain a tear and a smile.

A tear to purify my heart and give me understanding

A smile to draw me nigh to the sons of my kind.

A tear to unite me with those of broken heart;
A smile to be a sign of my joy in existence.

It is difficult to imagine anyone touching more lives than my father.  Over the past few weeks, many of you have shared his huge smile as the thing you will miss most.  What I find so remarkable is that, that smile was the result of many tears shed in sorrow for losses in his life outside of his control. 

I have learned one cannot have a truly unforgettable smile without shedding ample enough tears.

Dr. Saad Al-Agba was born in Baghdad, Iraq in 1936, and raised by a Turkish mother and Iraqi father.  His life was marked by tragedy almost from the start; he lost his father in battle at the tender age of five.  His mother was unable to speak Arabic, leaving him and his five siblings struggling to find their way.  His uncle, a teacher, became a stand-in “father.” Saad had to take over managing the family finances at nine, when his mother would give him the monthly pension check to divvy up for the food, shelter, and clothing needs for the seven in his family. 

There were days at school where clothes would be given out to the children who lost their fathers in war.  He had a great deal of pride and would stay home from school to avoid taking charity in front of others, even though his family desperately needed it. 

Full of entrepreneurial spirit, he started a number of small businesses selling toys and other handmade goods while in elementary school.  He took his family responsibility very seriously, and found himself apologizing to the principal at 11, on behalf of his 10 year old brother, who was in trouble.  The fact he was always cleaning up the messes of his carefree younger sibling was a bit of a thorn in his side. 

He worked hard and became a physician.  His first order of business after going into practice was to buy his mother a home of her own.  Shortly thereafter, his older sister was tragically widowed leaving her with five young children to raise alone.  My father helped her raise his nieces and nephews, just as his uncle had done for him so many years before. 

After journeying to England and then to the United States, he settled in Bremerton, with my mother, Barbara in January 1971.  There were abundant smiles during those early years for my mother and father after the arrival of two daughters, Laila in 1973 and me, 18 months later.  Tear returned when his beloved oldest daughter, Laila, drown in the shallow waters of Brownsville in 1975.  He never quite recovered, carrying the scar of this painful loss deep in his soul for the rest of his life.

As time passed, and other parents lost children, his tears and empathetic nature served to unite him with them.  He shared the same broken heart in a way few physicians or parents could even fathom. His ability to comfort a distraught parent through his tears and theirs was his gift to the world.  

He and my mother raised four children to adulthood, me and my three younger brothers.  He always made time for us despite running a bustling medical practice.  He could always be counted on for good advice hidden in esoteric philosophical statements, the message from which could take a few days for me to fully comprehend.

Joining his practice and being able to work side-by-side with him for 16 years was an extraordinary experience.  He had a wonderful way of sharing knowledge and we were always learning from one another.  Many patients benefitted from the “two-for-one deal,” basically the opinion of two physicians for the price of seeing one.  Sometimes, he would have me look at a patient and ask me to guess who they reminded him of, which had nothing to do with the practice of medicine;  though his grin would be a mile wide if I could read his mind accurately. 


Heartbreak found our family again when my little brother, Laith, died in an accident.  My father was out of town at a medical school reunion; we waited until he returned home to tell him so he was surrounded by his family.  Watching my father accept his son was no longer with us on earth will remain one of the most challenging moments of my life.  After that, his smile was never the same, yet continued to face the world with an admirable grace and endearing, yet subdued grin.


It was during that summer while filled with grief, my father said if he ever meets God, he would have one stone in each hand to throw at Him, one for his daughter and one for his son.  I told him God would understand, because he knows our hearts, He has a sense of humor, and most important, He lost his own son as well. 

Four grandchildren came along pretty quickly after that terrible summer and my father relished in his time with them.  When they were small and I was constantly pregnant and exhausted, he would come by every weeknight to help me bathe them.  I would not have made it through that challenging time without his loving assistance. 

As the grandchildren grew older, my father could be seen around town with them at Goodwill, Chuck E. Cheese, the bowling alley, Kohls, and McDonalds. He insisted the plain cheeseburger and milk was the healthiest meal on the menu and he was usually right when it came to such things.  We did tangle about whether chocolate milk should count as part of this nutritious meal, and with a twinkle in his eye, he reminded me to “let them live a little.” 

My father fought with death until the very end.  In reality, God likely waited until my father no longer had the strength to carry those two stones with him on the journey home.  That October day was probably memorable for God and my father as they went head to head.  I have no doubt he and God talked about many things as my father made peace.

“The deeper that sorrow carves into your being, the more joy you can contain.”

Over the last few weeks, I have realized while death played a larger role in his life than my father wished; his sorrow connected him to people in a way that was unparalleled.  His agonizing wounds allowed him to know unadulterated joy deep in his soul. It was his many tears and his big smile together, which made him so endearing, beloved, and revered.

In closing, I will share my favorite Kahlil Gibran poem, On Children:

Your children are not your children.

They are the sons and daughters of Life's longing for itself.

They come through you but not from you,

And though they are with you yet they belong not to you.

You may give them your love but not your thoughts,

For they have their own thoughts.

You may house their bodies but not their souls,

For their souls dwell in the house of tomorrow,

which you cannot visit, not even in your dreams.

You may strive to be like them,

but seek not to make them like you.

For life goes not backward nor tarries with yesterday.

You are the bows from which your children

as living arrows are sent forth.

The archer sees the mark upon the path of the infinite,

and He bends you with His might

that His arrows may go swift and far.

Let your bending in the archer's hand be for gladness;

For even as He loves the arrow that flies,

so He loves also the bow that is stable.

Reflecting on my father’s life and legacy, I will remember him as the bow that was stable.  There are countless stories of lives he saved and hearts he touched.  Just as God loves each arrow that flies, He loves the bow sending the arrows forth.  His last day in our office was Friday September 15; he saw 17 patients including one child with an allergic reaction to medication.  This heartbroken mother shared that my father saved her daughters’ life, providing care for which she will always be grateful. 

He spent a lifetime sending forth those he loved; including his nieces and nephews, me and my siblings, my four children, and many of you sitting here today, so each of us could go as swift and as far as possible. 

It is in heartfelt gladness we should celebrate and remember my father, Dr. Saad Al-Agba.  He knew the souls of the children for whom he cared would dwell in a future he would never see; yet, he accepted while he could not visit that tomorrow, even in his dreams, he could touch it in a small way through his connection with each and every one of us.  He freely shared his tears and his smiles with so many and for that; I thank God from the bottom of my grieving heart. 

Wednesday, November 8, 2017

Talking with a Four-Year-Old About Death and the Silver Can.

The past six weeks has been a challenging time for my family, my medical practice, my young patients, and my community.  My father, a pediatrician for more than a half century and my business partner for 16 years, lost his battle with heart failure, after a five-week hospital stay. 

While tackling difficult subjects with children is supposed to be within my expertise as a pediatrician, in reality, there is no “right” way to discuss the end-of-life with them.  It never hurts to lead with the truth.  My children, ranging in age from 4-9, visited my father in the ICU and each one asked if their grandfather might die.  Knowing his chances were less than optimal, I answered their questions as honestly as possible.

One child went every day with me to the hospital, one only wanted to see him twice, and the other two were somewhere in between.  The three oldest children cried, openly sharing their feelings during this journey; yet, my four year old was not as demonstrative, which is to be expected based on his developmental age.  

After my father passed away, each child has grieved in their own way, sharing things about him they will miss most, while my four year old has only said “I am sad papa died, mommy.” Knowledgeable on the developmental capacity at the tender age of 4, I considered excluding my youngest from the graveside service last week on the presumption he didn’t “need’ to see a process which he could not place in a larger context. That decision would have been short sighted. Instead, I asked my youngest child if he wanted to attend the service.  He chose to go with all of us to the cemetery.  It was a solemn affair and the children understood the significance of the occasion.  

At the conclusion of the service, my brother placed the metal urn into the grave and attendees dropped rose petals on top as they left.  Ten years ago, my father, brother, and I stayed after the service for my younger brother in order to shovel dirt ourselves.   As a matter of principle, I felt burying my father was a loving way to “take care” of him and show my respect.  Each of my children chose to be involved as well, something in which my father would have been proud.  

As we worked together, there was a quiet, contemplative energy to the endeavor.  The children took turns by handing off the shovel to one another while my husband and I helped guide their movements.  My oldest used the tamper and as the process reached completion and oddly, my heart felt calm for the first time that day.  “Helping” to bury my father appears to have given my children some much-needed closure as well.

They have returned to their regular activities with a comfort in knowing where my father is and accepting this life transition.  In the back of my mind, though, I still wondered about the perspective of my youngest son regarding the service. Then, a few nights ago, we had a notable bedtime conversation.   

He asked, “Why did they put papa in a silver can?” 

I answered, “They put his ashes in a metal container so they can rest in one place.”    

“Did they burn him?”  He asked.  Explaining cremation to a young year child was not necessarily something for which I had a prepared response, but I led with honesty.

 “Why can’t they put his whole self in the grave?” He astutely inquired.

The answer concentrated on the limitation of cemetery plots. 

“Why can’t we just dig a bigger hole?” To his credit, these questions were fitting ones.

“We could do that, but we wanted to honor papa’s wishes.”  I answered.

His next words reassured me his attendance at the service had been the right decision for him.  “Mom, I am glad we helped bury papa.  It was nice to take care of him and make sure he is cozy and warm.  I miss him and that makes me sad, but I know he is happy in the silver can.”      

“Sweetheart, I miss him too.  You are right, he is probably happy in the silver can.”  

While a four-year-old child has a different understanding of death than most of us, it is our job to help even the youngest among us process their experiences in their own time.  They will always land on their feet if we give them the space they need in which to do it in their own way.