Great service. Top clinical quality. Excellent value. Easy patient access.
Even ambitious executives hellbent on transforming their hospitals into worldbeaters would be unlikely to target more than two, or maybe three, of these goals for change at the same time.
But University of Pennsylvania Health System, Philadelphia, has pursued them all with a vengeance -- and succeeded. As a result UPHS will be named the winner of the 1998 National Quality Health Care Award this week in Washington.
The National Committee for Quality Health Care is a coalition of hospitals, healthcare organizations and suppliers to healthcare providers that is dedicated to defining and promoting quality healthcare. The committee initiated the award in 1993. UPHS will receive this year's prize at a ceremony Feb. 3.
Managing disease through standardized, evidence-based protocols in all settings -- ranging from a primary-care doctor's office to the cardiac intensive-care unit and even a hospice -- is the centerpiece of UPHS' quality approach. Starting with asthma early last year, UPHS developed 80 disease management protocols covering 38% of its patients by year-end. The health system is on track to have almost 83% of all patients treated that way by the year 2000.
Besides improving patient care at UPHS, disease management has fast become the glue binding the four hospitals in the system, which has $2 billion in annual revenues.
"Disease management is the final, common variable that integrates it all," said William Kelley, M.D., president and chief executive officer of UPHS. "It's so intuitive; there's no other way to solve these (organizational) problems."
First and foremost, UPHS has seized upon disease management as the key to improving outcomes. But, happily, treatment costs have fallen along the way. Length of stay for renal transplants has dropped to 8.7 days, almost half the baseline level of 14.8 days, at an estimated savings of $3.4 million. In another high-cost area, emergency room visits for congestive heart failure have fallen to an annualized rate of 75 per 1,000 patients from 256 before the program began.
Real teamwork and smoother operations are welcome, if slightly unexpected, outgrowths of the quality improvement campaign.
"I don't think I fully realized how important this was in tying the health system together," Kelley said.
In recent years UPHS, like other growing integrated delivery networks, has been busy buying or partnering with primary-care practices, adding alternate sites for care, such as a hospice, and, of course, acquiring and aligning with area acute-care hospitals. Simultaneously, the system has been taking more financial risk for its patients' well-being. UPHS has full-risk contracts for more than 150,000 covered lives.
Making the system work better, even as it increases in size and complexity, is a never-ending challenge.
"The sum of the parts should be more," said David Shulkin, M.D., chief medical officer and chief quality officer for the system. "But that's what (integrated delivery networks) are struggling to demonstrate." (Shulkin was chosen as a MODERN HEALTHCARE Up & Comer in 1997.)
That UPHS has done better than most stems from two simple-to-explain tenets that apply to every one of the 18,000 employees in the system: commitment and accountability.
Like the layers of an onion, UPHS has developed a series of report cards that grade the system overall and, in increasing detail, measure departments within the system and finally even individual workers.
Department employees, for instance, are measured on extensive quality and value scales tailored to their tasks.
And from CEO Kelley down to the floor nurse, pay is linked to report card scores. The link between pay and quality has elevated the improvement process to center stage instead of turning it into the latest fodder for Dilbert cartoons.
"You don't think of quality as this meeting you go to on a Wednesday afternoon," Shulkin said. "This is how you know you're doing a good job each day and every day."
In describing the report cards, Shulkin emphasized their balance. Quality, access, service and value are equally weighted.
"Organizations that have gotten themselves into trouble, like Columbia/HCA (Healthcare Corp.), focused too much on the value piece, while some academic medical centers have ignored value and developed the Rolls Royce of healthcare," Shulkin said.
Though daunting, a true commitment to improving quality can't be put off, despite the daily pressures of just running a hospital, said UPHS executives.
"If you wait for everything to fall in place," said Shulkin, "you'll be waiting a long time."
For instance, information systems may be the ultimate tools for improving quality. But even a forward-thinking institution like UPHS has trouble making sure all the computers that should talk to one another do.
Although UPHS hopes to have an electronic patient record up and running this spring, executives aren't banking on an electronic panacea.
Instead, UPHS has made measurement and reporting rituals the real focus, whether those results are delivered in meetings, in written form or at a computer keyboard.
Staying true to its academic roots, UPHS also is teaching others about quality. Shulkin oversees a one-year fellowship program that has given hands-on experience to a total of 11 physician executives while tapping their expertise for UPHS.
The system plans to disseminate its treatment protocols and quality lessons in both academic and commercial circles.
"Other people could do this," said Kelley, "and we'll try to help them."