"Please, Bob," Angela said. "We are all aware of the expense side to this disaster. Cynthia, continue! Do you think culturing and treating the staff and employees is critical?"

"Absolutely," Cynthia said. "And we might consider the same for patients as a prelude to admission. Both Holland and Finland had a particularly bad problem with MRSA, and the way that they brought their problem under control was by treating both staff and patients: anyone who tested positive as a carrier. I'm beginning to wonder if we might have to do the same thing. Yet my real concern is that the MRSA is occurring at all three of our hospitals. What does that say? It says that if a carrier is responsible, then that carrier must routinely visit all three hospitals. Consequently, I have as of today ordered the testing and treating of all employees from even here at the home office who regularly visit all three hospitals, whether they have actual patient contact or not."

"Anything else?" Angela asked.

"We have mandated aggressive hand-washing after each patient contact," Cynthia said, "particularly with the medical staff and nursing personnel. We've also instituted strict isolation for all MRSA patients, and more frequent changing of medical staff clothing, such as white coats and scrub outfits. We also require more alcohol cleaning after each use of routine equipment, like blood pressure cuffs. We've even cultured all the condensate pans of all the HVAC air handlers in all three hospitals. All have tested negative for pathogens, especially the strain of staph that has been plaguing us. In short, we are doing everything possible."

"Then why haven't the doctors been admitting patients?" Bob questioned. "As they are all owners, they have to be aware they are taking money from their own pockets by not doing so, especially if we go bankrupt."

"I don't want to hear that word," Angela said, having already been through that demeaning experience.

"It's clear why they are not admitting," Stewart said. "They are terrified of their patients getting a postoperative infection despite all the infection-control strategies. With reimbursement solely based on DRGs, or diagnostically related groups, patients getting a postoperative infection directly cuts down on their productivity, and it is productivity that determines their income. Besides, there's the malpractice worry. Several of our plastic surgeons and even two of our ophthalmologists are being sued over these recent staph infections. So it's pretty simple. Despite being equity owners, it makes economic sense for them to go back to University or the Manhattan General, at least in the short run."

"But all hospitals are having trouble with staph," Carl said, "particularly methicillin-resistant staph. And that includes both the University and the General."

"Yeah, but not over the last three months, nor at the rate we have been seeing it," Herman said. "And despite all these efforts that Dr. Sarpoulus has been spearheading, the problem has not run its course, given that we at Angels Orthopedic had another case late today. It's a patient by the name of David Jeffries."

"Oh, no!" Angela lamented. "I hadn't heard. I'm crushed. We'd been spared for more than a week."

"Like all the previous cases, we're trying to keep it quiet," Herman said. "As I said, it unfolded late this afternoon." For a few moments, silence reigned.

All eyes switched to Cynthia. The expressions ranged from anger to dismay to inquisitiveness: How could this happen after all that Cynthia had just told them was being done, with considerable funds that they did not have?

"It hasn't been confirmed it was methicillin-resistant staph," Cynthia snapped defensively. She'd been called by the hospital's infection-control committee chair and briefed on the case just prior to coming to the current meeting.

"If you mean it hasn't been cultured, you're right," Herman said. "But it was positive by our VITEK system, and my lab supervisor says she's never had a false positive: false negatives yes, but not false positives."

"Good Lord," Angela said, trying to keep her composure. "Was the patient operated on today?"

"This morning," Herman said. "Anterior cruciate ligament repair."

"How is he doing, or shouldn't I ask?"

"He died while being transferred to the University Hospital. For obvious reasons, once it was clear he had septic shock, he would have been far better treated over there."

"Good Lord," Angela repeated. She was devastated. "I hope you realize that was a bad decision. Sending two patients in as many days to a regular, full-service hospital raises the risk the media might get ahold of the story. I can just see the headlines: Specialty Hospital Outsources Critical Patient. That would be a PR nightmare for us and do what we are trying desperately to avoid: negatively affect the IPO."

Herman shrugged. "It wasn't my decision. It was a medical decision. It was out of my hands."

"How has the Jeffries family taken it?" Angela asked.

"About the way you would expect," Herman responded.

"Have you spoken with them personally?"

"I have."

"What is your sense; are they going to sue?" Angela asked. At this point, damage control had to be a priority.

"It's too early to tell, but I did what I was supposed to do. I took responsibility on behalf of the hospital, apologized profusely, and told all the things we have been doing and will do to avoid a similar tragedy."

"Okay, that's all you can do," Angela said, more to reassure herself than Herman. She made a quick note. "I'll inform our general counsel. The sooner they get on it, the better."

Bob spoke up: "If there had to be another postoperative infection, as tragic for everyone as it is, it's best the patient passed quickly. The cost to us is considerably less, which could be critical under the circumstances."

Angela turned to Cynthia. "Find out if the procedure was in one of the operating rooms that had just been cleaned. In any case, see that it is again taken care of, but don't shut the whole OR. And find out when all the involved personnel had been cultured and if any of them had been a carrier."

Cynthia nodded.

"Isn't there some way we can get our physician owners to up the census?" Bob asked. "It would be enormously helpful. We have to have revenue. I don't mind billing Medicare in advance if it is only for a couple of weeks."

The three hospital presidents looked at one another to see who would speak. It was Herman who spoke up: "I don't think there's any way to increase census, especially with this new MRSA case today. I don't know how my colleagues feel, but orthopods are very infection-adverse, because bone and joint infections have a tendency to stay around for a long time and eat up a lot of the surgeon's time, even in the best of circumstances. I've spoken about this issue with my chief of the medical staff. He's the one who clued me in."

"I've spoken with my chief of the medical staff," Niesha said. "I got essentially the same response."

"Ditto for me," Stewart added. "All surgeons are risk-averse when it comes to infections."

"It's probably too late, in any case," Angela said, trying to recover from this new blast of bad news. "But Bob's question gets to the heart of the reason I called this meeting. First, I wanted you all to hear about everything Dr. Sarpoulus has done concerning our MRSA problem. Of course, I wasn't aware there had been a new case. I'd truly hoped we were in the clear. Be that as it may, we have to somehow weather the next few weeks."

Angela then turned to Cynthia. "Angels Healthcare thanks you for your continued efforts, today's events notwithstanding. Now, would you mind leaving us for our boring financial discussion?"

Cynthia didn't respond at first. Her coal-dark eyes regarded Angela briefly, then swept around at the others. Without a word, she pushed back from the table and left the room. The door closed with a definitive thump.