Background of Internal University Review.
Last January, the University of Louisville announced that it was forming its own Internal Review Committee for University Hospital. In large measure, this must have been in reaction to the increasing calls for an audit of the Hospital’s use of the QCCT fund for indigent medical care. Indeed, the Auditor of State Accounts had already announced he would perform such an audit. Surely the University and its Hospital must already know a great deal about its own finances. After all, having a handle on internal finances is part of the job of running a hospital. Furthermore, for several years the University had been preparing for a merger/acquisition for which both internal and external reviews by the potential partners would have been mandatory as part of due diligence. University leadership admits it knows enough about the Hospital’s finances to submit an RFP to take on a new partner. Nonetheless, there is nothing wrong with taking a fresh look at the way any business is being run. Good for them!
This new committee did not emerge in a vacuum however. The University is emerging from a period of intense criticism of the way it interacts with its community– indeed that criticism continues. In my opinion the committee’s formation at this time is also part of an intensive and comprehensive public relations effort to improve or at least paper over its image. I believe this is a major reason why the offer was made that the review committee’s meetings would be open to the public. That is a major reversal of the tactics used by the University when it tried to merge with Catholic Health Initiatives and Jewish Hospital/St. Mary’s. In those proceedings, the University attempted to operate in secrecy until the last minute when it was forced to reveal at least part of its plans. The community did not like those plans. We now have an opportunity to see if the University and its leadership have changed their spots. This jury of one is still out.
Summary of the first meeting continued below.
First Committee Meeting.
I learned by accident of the Committee’s first meeting on the very day it was scheduled. I called to confirm the time, so they knew I was interested in attending. When I arrived, the only other member of the public in attendance was Mr. Patrick Howington, a reporter for the Courier-Journal. We of the public were outnumbered by three University and Hospital public relations officials. The full committee was present as were two other officers of University Medical Center, Inc. (UMC).
Before the meeting started I asked if it had been advertised and was told that because UMC was private, that they did not have to. To my mind, that choice deflated the initial admirable claim of openness to the public. My readers are free to form their own conclusions. I asked for a copy of the handouts that would be used for the meeting. None were initially provided and it was my impression that a decision had not yet been made to provide handouts to the public. I was later given a list of the committee members, the hospital’s mission statement, a skeleton agenda, and a copy of the charge to the Review Committee from UMC. I was not initially provided with a copy of the principal handout distributed to Committee members. [A copy was provided to the Courier-Journal, and when I requested it again the next day, to me as well.]
The Committee members introduced themselves. The majority are connected with the University, but there are also some very well-respected representatives of state and local government on the Committee. While we should all consider ourselves advocates for the disadvantaged, there were no traditional community-based or grass-roots advocates on the committee. I did not see any poor people in the room. I suspect all had health insurance.
“Oversee a review of the effectiveness and efficiency of University of Louisville Hospital’s operations and report its findings to the University Medical Center board of directors.”
The charge to the committee seems extraordinarily broad. If I were a committee member, I would not know what was being asked for. The committee members seemed to have the same problem. The charge was focused conceptually a little by adding a comparison of how the hospital compared to similar institutions doing similar things, and to define questions that the new consultants should be asked to respond to.
The request for feedback and comments from Committee members revealed that they were not all of one mind of what they should be doing or how it should be presented. The first UMC board member to speak wanted the process to stress the high quality of care provided, emphasizing the brand, highlighting the hospital’s care to the indigent and patients across the state, telling stories about how the hospital saves lives, and other themes that I would categorize as the public-relations-spin approach that the hospital currently uses. The highest-ranking University of Louisville official present wanted to emphasize how important it was that University Hospital profits continue to flow to the University of Louisville. This was not surprising to me.
The external members of the Committee had some very different perspectives. They said things like “what we did yesterday is not as important as where we are today nor what we should look like in the future.” They wanted to know what we would do with the results of the review and the answers to the questions asked of the consultant that would be hired that day. It was an outside committee member who said that an informed public will “certainly make it easier to talk about the potential arrangements made with people who might respond to the Request For Proposals for a new partner.” An outside member emphasized that the committee should have no preconceived ideas or agenda of how things will go. An outside member suggested that the results of the review and the recommendations by the soon-to-be-hired consultants would be useful to inform the RFP process. It was an outside member who told the committee they needed to be willing to address difficult issues including whether or not the state “needed two small medical centers.” He asked, “are two too many?” Objectivity was his goal. Not all the members of the committee (including its UMC board members) were acting as cheerleaders and I was reassured by their presence.
At least two of the committee members reasonably assumed that the work of the Committee and its consultant would inform the RFP process. I would have thought so too. This brought an immediate reaction from University representatives that I have reported on elsewhere and which I found troubling. The RFP process was categorized as a completely independent and parallel process that was on the same extremely short timeline as the Committee’s. The RFP process that would determine the future of University Hospital and University Medical Center will be conducted completely in the dark and independent of the Committee’s work. It was here that the claim was made that the University already knows a lot about the UMC financials can proceed (with UMC) to look for a new partner to manage the hospital. It was unclear to me whether this official was speaking for the University, UMC, or both. Is the Ad Hoc Committee’s major role only to provide cover for what the University wants to do anyway? Why does it seem that way to me? I hope to be proven wrong. My readers are free to form their own opinions.
1. a thing that is not what it is purported to be: the proposed legislation is a farce and a sham.
• pretense: it all turned out to be sham and hypocrisy.
• a person who pretends to be someone or something they are not: he was a sham, totally unqualified for his job as a senior doctor.
2. short for pillow sham.]
The initial discussion by the Committee did not come to any specific conclusions about how it should conduct its business. It appeared to me that a great deal of guidance about how to proceed was going to be expected from the consultants. Hiring a consultant for the process was the principal specific decision of the day’s meeting. Apparently, presentations from two potential consultants had been planned but due to the short timeframe, one was unable to appear. (Scared off?) The Committee heard a presentation from the firm of Craig-Anderson. Following the presentation, the Committee went into an executive session and approved hiring the firm. The presenters had remained in the hospital, presumably waiting for the decision.
The Committee was very much looking for direction from the consultants, but it was also clear that the consultants wanted and needed more specific directives from the Committee for a successful engagement. The consultants emphasized that the process was “compacted” into eight short weeks and that only a high-level analysis without implementation plans would be possible. There were practical limits to what they could accomplish in the brief time available. In response to an appropriate question of how the Committee could make the engagement most fruitful, the consultants suggested that desired outputs be clarified and that how the outputs would be used should be disclosed. “What are you going to do with the data? Just putting data on the table is not enough. What is it you want to accomplish?” These are reasonable, indeed essential questions to be asked by any consultant. After the consultants left, the Committee acknowledged that they would have to provide guidance in selecting the scope of the evaluation and to make it more clear what they were asking for. It seems to me that those decisions are very fundamental indeed, and the fact that they had not been settled previously magnifies the absurdly brief review period allowed.
I think that going into this review process, the University expected to be talking about numbers of indigent patients, the amount of uncompensated care they delivered, the need for more government money, and to affirm that they were using QCCT money wisely. With the addition of external Committee members, the scope of the possible review expanded greatly. Questions like: what should we look like in the future; or do we really need two (or with Pikeville, three) medical schools; or what will we look like without Passport; or what can we do to improve the less-than-desirable quality indicators at University Hospital; or how do we insure an informed public; or is it really okay to transfer revenue from an impoverished hospital to a university. Such questions are not going to be answered by a count of bodies and dollars. No one asked the question of why, when hospitals are springing up like mushrooms, there is no hospital in western Louisville? No one has asked the overriding question on which all else must follow: is it still acceptable to have a segregated healthcare system in today’s Louisville disguised even as it is under the cloak of “safety net?” Is quality medical care or even medical education really possible in such a system? I think we have a once-in-a-generation opportunity to talk about such things. These are decisions that must be embraced by the Community of Louisville as a whole, and not by the University of Louisville alone. I do not see this happening at the present time. Instead I see a self-serving rush to a preconceived solution.
Secrecy. Has anything changed?
Will this internal review, limited as it is in time and scope, truly be done in the public eye? Again, I hope so, but I remain skeptical. It was stated at this first meeting that to decrease the number of physical meetings, some of the business of the committee would be conducted by an email-circle. I asked if I could be included on the distribution list and receive the information the Committee members did. Of course any such possibility was a dream of my fevered but well-meaning imagination. I was informed that any significant matters impacting the committee’s work will get addressed at meetings. The definition of “significant” now lies in someone else’s hands. However my overall first impression is that the University and its Hospital are still not comfortable operating in the public eye. This is an old habit and will be difficult to change. The University’s ongoing litigation asserting the private status of its hospital and its various Boards and affiliated organizations is not a good omen.
Peter Hasselbacher, MD
Feb 26, 2012