University of Louisville Hospital Pledges To Do Better.

I was both pleased and proud to read yesterday’s letter in the Courier-Journal by Ken Marshall, President of University of Louisville Hospital, recommitting to a higher quality of medical care for our community, including its most vulnerable citizens. Alas, under the clinical and management captivity by Catholic Health Initiatives and KentuckyOne Health, the hospital has performed unfavorably in virtually every quality-comparison with other hospitals, including other teaching and safety-net hospitals. Indeed, major layoffs of clinical and support staff by KentuckyOne, and concerns about quality of care by some staff physicians drew Federal attention that threatened the Hospital’s accreditation.

Various of the many items measured and methodologies used by the numerous evaluating entities have been criticized, and in my opinion sometimes rightly so. After all, what constitutes quality? One major criticism of current federal and proprietary hospital quality assments is that they do not adequately take into consideration the socio-economic status or severity of illness in the patient populations served. With all the valid current emphasis on the nonmedical determinants of health care status and outcomes, how can we not take these into consideration? Nevertheless, for University Hospital there is nowhere to go but up.

Proud and nervous at the same time.
Proud I was at this full disclosure and assumption of responsibility, but squirm I did because Mr. Marshall was obviously preparing us for yet another bad review. And so it came. I was aware that the Leapfrog Group had disclosed their Fall 2017 Safety Grades to the nation’s hospitals prior to their public release. The scores made public today once again give the University of Louisville Hospital a letter grade of ‘D’. Kentucky’s fellow travelers in the ‘D’ Category include Jewish Hospital, Saints Mary & Elizabeth Hospital, and Lourdes Hospital. At this revelation, I actually breathed a sigh of relief because I feared we were being set up to learn that we were one of the 15 hospitals nationwide to be graded with an ‘F’ – the equivalent of University Hospital’s most recent overall Medicare quality score of ‘One Star.’ Rather, we are one of only 159 ‘Leapfrog-D’s nationally – in the bottom 7% of Leapfrog-evaluated hospitals. It is  correct to recognize that, as for all hospitals, both the Medicare and Leapfrog scores are based on information that can be quite outdated.

I have written a good bit about quality evaluation of hospitals and recently accumulated enough data to test the hypothesis that teaching and safety-net hospitals face a more difficult challenge scoring highly in these quality comparisons. I hope to present the results at a later time. Strictly speaking, the Leapfrog scores attempt to quantify ‘Safety’ by selecting from a variety of federal and proprietary measurements used in broader evaluations of ‘Quality.’ Nonetheless, a hospital that is not safe cannot lay claim to very much quality.

Let the Hospital do its job.
It is going to take more than choosing a different evaluator or peer group to demonstrate that things are actually getting better at University Hospital. We cannot blame every problem facing the Hospital on KentuckyOne. Indeed, University Hospital received a ‘D” or worse from Leapfrog as early as June of 2012 before KentuckyOne took over. Convincing our community that things are different will, as Mr. Marshall affirms, require major changes in the status quo. For the 33 years that I have lived in Louisville, including the 13 years in which I served as an attending physician on its teaching services and as Chair of its Pharmacy and Therapeutics Comittee, University Hospital has not been a hospital of choice for people with other options. This perceived status by the community antedated hospital control by Catholic Health Initiatives. It will take major changes in the way the University views its relationship with its Hospital to make any difference. Instead of using the hospital as a cash cow to fund research, general University programs, and high salaries; the Hospital’s profits must be rolled back for its exclusive benefit. Indeed, had this been done from the start, it might never have been necessary to hand control of the Hospital’s agenda over to a nonacademic religious entity.

For starters, real change is going to require greater physical presence of University clinical faculty on the wards, with a corresponding degree of increased hands-on supervision of students and trainees who do the day-to-day work in the hospital. The hospital must be seen by its clinical faculty and the patients they serve in their private practices as a better than acceptable place to be admitted. There must be more skin in the game! Separate and unequal status as has existed is unacceptable. The various clinical services must work in a more coordinated way. The clinical departments must once again honor teaching and clinical service with their highest priorities. The University of Louisville has strayed from those priorities. The clinical departments and hospital were, in my opinion, intentionally starved to benefit the commercial research enterprise of the University and to gain control of clinical income. A hospital whose clinical care is not excellent cannot be an excellent place to learn medicine, nor to do research.

No Governors or Bishops allowed in the hospital rooms.
Lastly in this non-exclusive list, the Hospital must not be seen to compromise its standards of care by cowering against the intrusion of inappropriate, frankly political, or religious influence. The hospital and University hurt themselves badly by doing so these past 5 years. It can start by resuming the contract it had with Planned Parenthood and other abortion providers to accept patients with complications of related surgical procedures. It can also be honest about where the pressure to cancel those agreements came from in the first place! What patient would not want to know who else was in the examining or hospital room with them and their nurse or doctor?

Somewhere other than Oz please.
More can and will be offered by others. For now, I am cautiously optimistic that we will see real change for the better. I sincerely want that to be the case and wish I could do more to help. However, the University of Louisville and its partner foundations and corporations, its Medical School, and the Downtown Medical Centers have been pulled into an existential tornado from which I doubt anyone knows where or when  they will be set down. I wish my former colleagues at University Hospital both the courage, strength, and resolve to do what they know to be in the best interests of their patients, students, trainees, and community.  I believe my former colleague Mr. Marshall sincerely wants to set a new course but he needs to be empowered to move the rudder. The Hospital cannot do it alone and will need support. That help will follow a demonstration of real change, no matter how it is measured.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
President, KHPI
October 31, 2017