Medical overseer takes no prisoners

SACRAMENTO -- One of the most powerful figures in state government is a cranky authoritarian who can spend unlimited amounts of taxpayer money, overrule high-ranking bureaucrats and sidestep long-standing laws.

From a nondescript office building in San Jose, Bob Sillen uses his unprecedented authority to tackle one of the toughest jobs in California: rebuilding the medical care system for the state's 172,000 prison inmates.

Sillen, who earns $500,000 a year, was appointed by a federal court judge to bring prison medical services up to "constitutional standards." He has, in effect, replaced the governor, Legislature and top corrections officials as chief policymaker on prison medical care matters.

As he marks his first anniversary this week as court-appointed receiver, Sillen has done precisely what those who know him would have expected: He has earned the respect of many inmates and prison employees by dramatically improving health care for those who have the least access to it.

He has retained staff and improved quality by granting generous raises. Patient lab results come back weeks earlier. Inmates see specialists much sooner. And he is introducing computer technology to give doctors better access to medical histories.

But, also as expected, he has drawn the ire of public officials and others with his lightning-fast changes and dare-me-to-do-this attitude.

For example, early in his tenure, Sillen suggested that state officials Advertisement were slow to boost the abysmal salaries of nurses, doctors and pharmacists, then charged ahead with a court order to waive state law and grant huge raises -- up to 64 percent. The raises cost the state $25 million but are supposed to save even more by reducing the use of nursing contractors.

He also took on the powerful correctional officer's union and the state personnel board by swiftly eliminating a job classification that allowed hundreds of prison guards to perform nursing duties.

All along, he has angered legislators with repeated threats to raid the state treasury and to sue the pants off anyone who obstructs him.

Sillen earned his aggressive reputation during his tenure as head of the Santa Clara Valley Health and Hospital System.

"Bob Sillen is a difficult person, but you always know that the patients are his highest concern, and he will fight very hard to make sure that patient care is a priority," said Kristy Sermersheim, of the San Jose-based Service Employees International Union Local 521, which represents 50,000 hospital employees and other workers. "He really doesn't worry about bureaucracy, which he hates."

Sillen suggests that adversaries shouldn't be so shocked by his in-your-face ways.

"Dalmatians don't lose their spots," said Sillen, 64, who worked for Santa Clara County from 1979 to 2006, "and I'm an old Dalmatian."

For some, he is exactly what the system needs, given the daunting challenges of a culture slow to make improvements, a powerful union accustomed to influencing policy and politicians who see little to gain in helping inmates.

"This has been a major shake-up for corrections in California," said Sillen supporter Sen. Gloria Romero, D-Los Angeles, the Senate's Public Safety Committee chairwoman and the Legislature's loudest critic of the pace of prison reform. "Not only has he impacted the budgeting and the priorities for corrections in California, but his powers have tested the independence of the three branches of government by which we live."

Some lawmakers, particularly Republicans, are so angry at the position created by U.S. District Court Judge Thelton Henderson that they've demanded hearings to challenge Sillen's authority.

"To have an outside party brought in and given carte blanche in your checkbook is a very strange situation," said Sen. Dave Cogdill, R-Fresno, the ranking Republican on the Public Safety Committee, "and one I hope we can remedy quickly."

Sillen, who refuses to move from his Santa Clara home to live or work in Sacramento, the state's political epicenter, has a long road ahead. The prison crisis, blamed on severe overcrowding and the inattentiveness of elected officials, developed over decades, and will take years to resolve.

Henderson seized control of the dysfunctional medical-care system June 30, 2005, as the result of a class-action lawsuit filed in 2001. An inmate was dying about every week because of medical negligence or malpractice, Henderson said at the historic hearing where he detailed a list of broken promises made by prison officials dating back 25 years.

Federal receivers also oversee mental health care, dental care and compliance with the Americans with Disabilities Act, although none have as much authority as Sillen.

"He's decisive, he knows what he wants, and how to get it," Henderson said, further suggesting that Sillen excels at "cutting through the bureaucratic red tape, cutting through resistance of people."

Sillen didn't fully know what he was in for until his second day of work, April 18, 2006, when he toured San Quentin State Prison. Among his lasting impressions: the medical staff's inability to keep in stock basic supplies such as gauze bandages and the lack of running water in an examination room.

He said he "put San Quentin under a microscope" as a test lab for the 33-prison system. He promised to construct a $146 million hospital, order physical exams for new inmates, reduce the backlog of hundreds of patients needing specialty care and increase staffing.

Many of the tasks have been completed, including adding 41 new positions, administering physicals in a private screening area and resuming prisoner access to off-site specialists after settling the state's unpaid debts to those doctors.

Employee morale has improved now that their jobs offer pay similar to positions outside prison walls.

"The glass is half full, and it's filling up," said Tim Devereux, a newly hired physician assistant at San Quentin. Working conditions and patient care, he said, are "getting better continuously."

But while receiving high marks for his San Quentin project, Sillen has been sharply criticized for moving too slowly at other prisons.

"One of the first things I sent to the receiver, when he began in April, was a list of the prisons most in crisis," said lawyer Steve Fama of the Prison Law Office in San Rafael, a nonprofit group that was instrumental in the proceedings that led to the receivership.

Avenal, off Interstate 5 near Coalinga, was the most medically understaffed prison, Fama said. Three inmates died there in December because of "inadequate care and lack of physicians," he said.

Sillen attributed the deaths to "the result of one or another kind of neglect." He responded by sending doctors from other prisons, dispatching a team of physicians from UC San Francisco and creating 70 new positions at Avenal.

"What he's done at Avenal is terrific," Fama said. "It's just a shame that it took so long for it to happen."

Sillen concedes that the medical system remains imperfect and continues to reflect unconstitutional "cruel and unusual" punishment.

"The deaths continue, far too many as far as I'm concerned, and the neglect and lack of caring continues," he said. "It's going to take time to take care of that."

A total of 340 inmates died in custody the year before Sillen took over, and 320 have died under his watch, according to prison statistics. How many of those deaths were preventable is unknown.

Sillen rises as early as 3 a.m. to send e-mails to his two dozen staffers, then heads to the gym two hours later. Much of his work takes place in the sparsely furnished offices of the California Prison Health Care Receivership Corp., within jet-engine-earshot of the San Jose airport.

Sillen tours about two prisons monthly and regularly expresses his opinions to Gov. Arnold Schwarzenegger and other top officials. He occasionally appears at public hearings, which are contentious when his answers don't satisfy bureaucrats' most pressing questions: How much is this going to cost? How long will it take?

H has used $59 million of a $100 million first-year appropriation but insists that it is too early to estimate future budgets for a job that may take at least 10 years.

Some key officials cite an uneasy relationship with Sillen, often because of a lack of communication or because he answers only to a federal judge.

"The relationship is still somewhat testy, and it could be better," said Sen. Mike Machado, D-Stockton, chairman of a budget subcommittee before which Sillen testified. "And in order to get to the point where the state can assume control over the medical provisions, it's going to take developing a greater partnership than now exists with the receiver."

Department of Corrections and Rehabilitation Secretary James Tilton, who supports fixing the system's medical component, acknowledged a sometimes-awkward relationship with Sillen, because the receiver can make widespread decisions for the agency that Tilton then has to implement.

"It's fair to say that Mr. Sillen has a clear mandate from the court and I want to make sure that I'm not a barrier to that," Tilton said, "because I don't want him to throw me in jail and hold me in contempt."

Sillen has experienced a few public flare-ups, including a quarrel with the State Personnel Board over his opposition to pre-employment drug testing for licensed vocational nurses and his desire to bypass civil service protections so that he can fire incompetent doctors.

He also takes swipes at the state government in his reports to the federal court.

In his first report, dated July 5, he noted a "culture of incompetence and non-performance" among state employees. In his fourth report, last month, he took aim at the Department of General Services for its "failure to cooperate" with a pharmaceutical management contractor he hired to save millions of dollars. He called the department's conduct "trained incapacity."

Peter Farber-Szekrenyi, a Schwarzenegger appointee to oversee prison health care who was forced to resign after clashing with Sillen, said Sillen's "confrontational" style "makes it harder to work with people."

"Probably his style has been criticized more than once, and probably by more than one entity," said San Quentin Warden Robert Ayers. "But if you look at the overall strategy of where we're going, I think it's probably going to work in getting us there."

BIOgraphy

NAME: Bob Sillen
AGE: 64
TITLE: Federal receiver overseeing California's prison medical care system since April 17, 2006; responsible for inmate medical care in 33 prisons
WEB SITE: www.cprinc.org
EDUCATION: Bachelor of arts, University of Denver; master's degree in public health, Yale University
PAST EXPERIENCE: 1979-2006, leadership roles in Santa Clara County's health and hospital system
HOME: Santa Clara

Big bucks in inmate care
FIVE HIGHEST-PAID PRISON HEALTH EMPLOYEES
Bob Sillen, receiver, $500,000*
Terry Hill, chief medical officer, $350,000
Justin Graham, chief medical information officer, $275,000
John Hummel, chief information officer, $275,000
Rich Wood, chief financial officer, $275,000
*Includes $50,000 annual incentive
Source: California Prison Health Care Receivership Corp.

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