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How to Run a "Safety Net" Health System

Accompanied by her family, Patricia Gabow holds her Distinguished Graduate Award.

By now, Patricia A. Gabow, MD 1969, GME 1973, is probably used to standing out in a crowd. As a student in the University of Pennsylvania’s School of Medicine, she was one of only six women to graduate in a class of 125. During her 20-year tenure as CEO of Denver Health, Modern Healthcare magazine named her one of the 100 most powerful people in the field as well as one of the most powerful physician-executives. Her other honors include the AMA Nathan Davis Award for Outstanding Public Servant and the National Healthcare Leadership Award.

When Gabow returned to the Penn campus last year to receive one of the Perelman School’s highest honors, she became only the ninth woman to receive its Distinguished Graduate Award out of a total now of 71 recipients. Most of her fellows in this exclusive group were selected for their research. Although Gabow has made her mark as a nephrologist and a professor and has widely published, her most visible achievement may be having led Denver Health for 20 years. As the principal “safety net” institution for Colorado, it serves a large population of low-income, uninsured, and vulnerable patients. During her return to Penn, she was asked how, as a physician, she was able to do what she did. “Wharton people might object,” she replied, “but it was my preparation as a physician.” You begin by making a diagnosis of the problems facing the institution, she explained, then develop a treatment plan. And, she emphasized, you need sound data, like any researcher. Last month, in a Commentary in Academic Medicine, she explained in more detail how she was able to transform Denver Health, as the document with her Distinguished Graduate Award put it, “into a national model for its superior quality of care.”

Noting the huge gaps in health and health care across socioeconomic and racial/ethnic groups, Gabow argues that meeting the challenge “is primarily an issue of improving the well-being of the most vulnerable.” That was a task traditionally met by “safety net” institutions, but with the increase of Americans having health insurance, the challenge is now broader. Denver Health’s path included two primary steps: creating an integrated system of care for the population of Denver and creating a robust approach for quality, cost reduction, and employee engagement.

The Many Components of a Health System

To address the needs of the community’s vulnerable population, Denver Health developed or brought together several different components: a Level I trauma center that provides care for victims of violence as well as numerous resources for mental health care; nine ambulatory care centers located in underserved neighborhoods, which provide ready access to primary care; 16 school-based clinics, located in high schools and middle schools; and an integrated call center that includes round-the-clock nurse advice and also provides some prescriptions. Denver Health also offers correctional care to patients in the criminal justice system. In addition, there is a health maintenance organization wholly owned by Denver Health that seeks to provide seamless care as well as a 911 paramedic system. Equally necessary is a single electronic health record platform that links the entire health system.

Denver Health was established by the Colorado legislature in 1860; its governance was later transferred to the City and County of Denver; and it is governed since 1997 by an independent hospital authority. The overall situation in Philadelphia is different. The city’s safety-net hospital used to be Philadelphia General Hospital, which served the city’s poor for 245 years before closing in 1977. In West Philadelphia, however, the hospitals of the University of Pennsylvania Health System have absorbed much of that patient population. In addition, there are ambulatory-care centers like the Perelman Center for Advanced Medicine and Penn Medicine University City; student-run clinics in the neighborhoods; the school-based Dr. Bernett L. Johnson, Jr. Sayre Health Center; and Puentes de Salud, which serves South Philadelphia’s rapidly growing Latino immigrant community.

In Academic Medicine, Gabow also cites the importance of having a substantial presence of employees from the surrounding communities. “This not only provides a sense of comfort and trust to the patients but also, in part, addresses the issue of poverty that clearly influences the community’s health.” In 2011, for example, 41 percent of Denver Health employees were from minority communities.

The Goal: Constant Improvement

How to maintain such a complex, integrated system? In her Commentary, Gabow writes that it was necessary to create “a disciplined and structured approach to financial stability, high quality of care, and employee engagement.” To realize those goals, Denver Health chose Lean, a management and quality-improvement approach based on the Toyota Production System. As Gabow put it during her visit to Penn, the system is built on respect for the customer and constant improvement. (In 2014, Gabow and Philip L. Goodman, former director of the Lean initiative at Denver Health, published The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System.) Over the course of several years, Gabow continues, everyone in a leadership role was trained in Lean – and was expected to use Lean every day to remove at least $30,000 of waste each year. By three years, these “Black Belt” units were achieving an average of $110,000 savings per year. From 2006 through 2011, according to Gabow, the Lean effort achieved a “total financial benefit” of nearly $195 million.

Another advantage of Lean, Gabow writes, is increased employee satisfaction and engagement. Using the Lean tools, employees learned to see and eliminate waste by developing new processes. In all, more than 2,000 employees were involved in “rapid improvement events,” four-day events aimed at developing strategies to reduce waste in a particular area.

Denver Health’s efforts were noticed nationally. In 2011, it received the Shingo Bronze Medallion for Operational Excellence, associated with the Jon M. Huntsman School of Business at Utah State University. Denver Health was the first health care entity to receive the honor.

During her Penn visit last year, Gabow emphasized that “the only reason we were there was for the patient,” but she believes the business side of health care remains the largest challenge. She also mentioned how pleased she was to see how team-based learning has taken root at the Perelman School, encouraging students to study together and solve problems together, and also noted that many of its students are also earning degrees in other disciplines. In the complicated, many-sided world of contemporary medicine, that breadth of interest and learning can only help both physician and patient.

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