Santa Catalina Island may lie only 26 miles off the coast of bustling Los Angeles, but for those who inhabit the tiny rustic isle-where cars are prohibited and buffalo nearly outnumber the locals-it often feels like a world away.
No one is learning this faster than William Greene.
In January, the 59-year-old healthcare veteran left behind the big-city amenities of the mainland to head up financially struggling Avalon Municipal Hospital and Clinic, the island's sole medical facility and Los Angeles County's only rural hospital.
As 12-bed Avalon Municipal's first chief executive officer to live on Catalina full time, Greene has had to adapt quickly to the idiosyncrasies of island life while tackling the unique challenges facing the state's smallest and most medically remote hospital.
"It's a whole different ballgame out here sometimes," says Greene, who was previously president and CEO of 39-bed Santa Paula Memorial Hospital, a former Quorum Health Group facility just north of Los Angeles.
Indeed, Catalina is a place where its only full-time doctor makes house calls on a golf cart, where people can recite the boat schedule by memory, and where phone numbers are given in four digits because everyone shares the same 510 exchange.
The island's main town of Avalon was founded by chewing-gum baron William Wrigley Jr. in 1919. It is home to just 3,200 permanent residents, all of whom pick up their mail at a central post office and go days without milk or bread whenever storms prevent shipments from the mainland.
This relative isolation-while a draw for the 1 million tourists who flock to Catalina each year-poses serious challenges for 41-year-old Avalon Municipal Hospital, which has never been profitable and continues to totter on the brink of financial collapse.
According to the California Department of Health Services, Catalina is the state's most medically remote community. Injured patients in need of emergency care must be airlifted by helicopter-often at the hospital's expense-to the nearest full-service medical center on the mainland some 30 minutes away.
At the same time, the city-owned hospital averages only two patients a day, hardly enough to cover its overhead costs. And because the quaint single-story facility is surrounded by water, it can't pick up additional business from neighboring markets as do other rural hospitals.
"Our remote location limits (the hospital's) growth and drives up the cost of healthcare," says Avalon City Manager Robert Clark. "We have always had to spread large costs over a small number of people."
As a result, Avalon Municipal has faced possible extinction several times over the past decade. It nearly shut down in 1992 when its mainland affiliate, 726-bed Long Beach (Calif.) Memorial Medical Center, announced that after eight years it could no longer afford to manage the facility, which was losing roughly $30,000 a month.
At the time, some experts recommended that Avalon replace its hospital with a bare-bones "super-clinic" that would refer patients in need of hospitalization to the mainland. But largely at the urging of local businesses, the city instead agreed to pump $520,000 into keeping the hospital's doors open.
"We looked into the super-clinic concept, but it just didn't fly for this community," says Wayne Griffin, president of Avalon's Chamber of Commerce and a trustee on the hospital's five-member board. "While it would have saved us several thousand dollars a year, it didn't provide skilled nursing, which is important for our residents' continuity of care. Also, because Catalina's sole economic base is tourism, it's crucial that visitors to the island feel safe and know that, if they get sick, there's a real hospital here to treat them."
By the time the University of Southern California's Department of Family Medicine began managing the hospital's administration in November 1996, Avalon Municipal was hemorrhaging money so severely that it was forced to borrow another $140,000 from city coffers to continue operating.
For a while, USC managed to stem much of the losses, and at one point even generated $50,000 toward repaying the hospital's debt to the city. But by May 2000, with its finances once again spiraling out of control, Avalon Municipal severed its ties with the university and decided, once and for all, to go it alone.
"We were getting lost in the shuffle with these large mainland partners," whose priorities lay elsewhere, Griffin says. "We decided we needed an administrator who would focus on this hospital alone and whose only loyalty would be to this community."
The search begins
In desperate need of a new hospital CEO, Avalon city officials invested $30,000 to hire the Rokos Group, a healthcare executive search firm based in Irvine, Calif. Together, the parties hammered out three main criteria for prospective candidates:
* First and foremost, Avalon Municipal's new CEO would have to live on the island.
City officials were tired of hospital administrators who, eager to return to their homes and families on the mainland, put in shorter and shorter workweeks before inevitably quitting or getting fired, Clark explains. (Turnover at Avalon Municipal has been so high, in fact, that the hospital's receptionist professes to having worked under 21 administrators in the 20 years she has worked at the front desk.)
"We've learned that it's very hard for people to function if they don't live here on the island. When they try to commute back and forth, pretty soon they're showing up late Monday and leaving late Thursday afternoon," Clark says. "For a hospital of our size, it's very important for the person in charge to be on site not only during the normal workweek but also on the weekends, in case something comes up."
* Second, the new administrator would need to have ample experience in a rural setting as well as strong financial skills, largely because Avalon Municipal can't afford to hire a separate chief financial officer.
"In a small rural hospital, you don't have the luxury of a large staff working for you. The CEO has to be able to wear several different hats," says Greg Rokos, founder and president of the Rokos Group.
* And third, the hospital's new chief would have to be very hands-on. "The city wanted someone who, if a tile breaks on the (hospital's) roof, will be up there in his boots, hammering," Rokos says.
With these criteria, the Rokos Group worked its contacts and placed job advertisements in various publications, including Modern Healthcare. Initially, the prospect of living on beautiful Catalina Island was enough to draw almost 100 applicants from around the country. But candidates began to bow out once they realized what the position really entailed.
"A lot of people from places like Colorado, Iowa and Maine were totally gung-ho about the idea of moving to a picturesque island off the coast of sunny California," Rokos says. "But that was before they had evaluated things like transportation and the cost of living."
One of the main deterrents, Rokos says, was Catalina's moratorium on cars. Because space on the island is so tight, residents must tool around in golf carts while waiting 12 years to receive a full-fledged auto permit.
Another major impediment was the island's exorbitant real estate prices. Because Catalina's vacancy rate is virtually zero year-round, houses and apartments there can sell for three times what they cost on the mainland. And many of the homes that do become available are too small for families with children.
Greene and his wife, Trish, however, had visited Catalina a number of times as tourists and were familiar with the island's quirks. What's more, the couple had raised six children-all of whom now live in Colorado and Michigan-and were happy to settle down in the quietude of the small house the hospital had set aside for its new administrator.
By the time Greene heard of the opening at Avalon Municipal, he already had decided to leave Santa Paula and was considering career opportunities back east. But the more he learned about Avalon, the more he was won over by the strength of its tightknit community.
The clincher, he says, was when the city voted last October to boost its sales tax by one-half percent to 8.75%-the highest level in all of California-solely to preserve the hospital. "The rate hike was approved by a resounding 76% of the community," Greene says. "That show of support really impressed me. It's a very strong statement."
In December, Greene was chosen from among four finalists for the top spot at Avalon Municipal. His sound grasp of rural healthcare and broad experience working with both large and small hospitals made him a shoo-in for the complex position, members of the search committee say.
Greene grew up in Traverse City, Mich. After earning a master's degree in health facilities administration from the University of Georgia, he headed up a number of hospitals, including 80-bed Saint Joseph's Community Health Services in Hillsboro, Wis.
"Bill is no stranger to the rigors of running a small rural hospital and has experienced many of the issues we have," Clark says. "It was also a real plus that Bill had worked for a large company that manages small rural hospitals (Quorum), because that gave him a lot of corporate expertise that he can bring to bear in a small community like ours."
Home sweet home
Greene and his wife have adjusted well in the five months since they hauled their belongings to Catalina on a barge.
Granted, the 1,500-square-foot, single-story house they rent in the steep hills of Avalon is markedly smaller than the 2,200-square-foot, two-story home they owned in Santa Paula. And their new space-saving golf cart leaves much to be desired compared with the roomy Lincoln Town Car they left on the mainland.
But Greene says they've found pleasure strolling along Avalon's Mediterranean-style harbor and down Crescent Avenue, a pedestrian mall, where locals invariably greet them by their first names.
And by all accounts, Greene is adapting equally well to his new work environment.
The bespectacled executive shares a 10-by-10-foot office at the far end of the hospital with his administrative assistant. Although admitting the space is almost Lilliputian compared with his former offices on the mainland, Greene seems unfazed by his cramped surroundings.
"Once you're sitting at your desk and working, it's all the same," he says.
Greene's immediate priority is to find a replacement for Georganne Sanders, who left Avalon Municipal in April after serving two years as the hospital's only full-time doctor. Sanders came to the island as part of a rotational physician program the hospital forged with USC in 1996. That arrangement was terminated last month.
Like other small hospitals in remote areas, Avalon Municipal has long struggled to attract and keep doctors, nurses and lab technicians. But now, the hospital is having to make do with four temporary physicians, who rotate from the mainland every five to seven days.
The new administrator plans to apply for more federal grants and has set out to ease Avalon Municipal's cash-flow problems by overhauling its billing and collection process, which he calls "broken."
With its high management turnover, Avalon Municipal has had a long history of underbilling third-party payers and, in some cases, not billing at all. By the time USC began managing the hospital in 1996, it had more than $2 million worth of services that had gone uncollected.
"We're making good headway," Greene says. "We've just about gotten through a huge pile of old bills that had been sitting on the office floor for the past six months."