Q & A
David Shulkin
BY JASON CLAMPET
David Shulkin, chief medical officer and chief quality officer of the Health System, is a busy man. When journalists need a quote from a hospital official, they dial Shulkin. The German daily Die Welt rang him to find out how last summer's satellite malfunction affected the beepers and cell phones of the the hospital's medical staff.
When he's not fielding calls from journalists, he's speaking at a conference, overseeing the system's hospitals and doctors, or finding time to practice general medicine. He must be able to juggle this competently: last year he personally pulled in two major medical leadership awards. To fit this interview into his busy schedule, part of it was conducted through e-mail.
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The chief medical and quality officer of Penn's Health System has made an opportunity out of the challenges of adjusting to managed care. Photo by Candace diCarlo |
The Hospital of the University of Pennsylvania has garnered three significant awards of its own during his tenure. In the past year it won the National Quality Health Care Award, the Excellence in Healthcare Award and the Ernest A. Codman Award, and was one of 14 hospitals selected from a field of 6,400 for U.S. News and World Report's honor roll.
Most of this has been done in the atmosphere of rising health costs and the tiring obstacles of managed care.
Q. How has HUP altered the way it does medicine since the emergence of quality awards and report cards?
A. The emergence of public profiling of outcomes data was really more of a wake-up call for us. We examined this public data and we recognized the limitations of their methodology.
This drove us to develop, in turn, our own measures of quality, ones that fit our institutional needs. We didn't want to be in a position where people external to our system were reporting on our outcomes before we thoroughly understood them ourselves.
Q. What steps has HUP been taking in the last few years to provide the type of services that are recognized by award-granting bodies?
A. We do not really set out to win awards - rather, we set our goals towards trying to create an environment that continuously worked to improve the care delivered to our patients.
Early in the decade, we put into place the resources necessary to understand and measure the factors that impact most on clinical care in our system. And once we began to identify and track these factors we developed tools and interventions to improve clinical outcomes.
Q. What special concerns does a university hospital have, in terms of care and relationship to the community, as opposed to a for-profit operation?
A. HUP has a tripartite mission to support superb clinical care, education through the training of residents and students, and research to advance the science of medicine. We devote significant resources to each of these missions. A for-profit hospital tends to focus on where they can achieve the best return for their shareholders and may look upon their mission as different from ours.
Q. What type of systems has HUP developed to address some of the challenges of managed care?
A. We've taken several significant steps.
When we developed our health system in 1993 we created a fully-integrated regional system that now allows us to establish full-risk relationships with the managed care organizations - we manage the patients' health and they manage the paperwork.
These contracts are extremely important strategically. They allow for us as providers to determine the appropriate clinical standards of care and allow the HMOs to concentrate on the administrative functions of supporting a contract.
Our development of health and disease management programs becomes increasingly important for us as we operate these contracts and implement the best-practice approach [finding the best way to attack an illness] to medical care.
These programs allow us to provide the highest level of care, as defined by us at Penn, and not have this defined for us by the HMOs.
Q. How has the expansion of HUP over the last decade changed the way HUP views its role within the Philadelphia community?
A. With the development of our health system we have tried, and I believe succeeded, to truly become a regional provider of care in the greater Philadelphia region. Actually, there is now more patient activity that happens outside of our West Philadelphia campus than we do on campus. We have developed primary care capability, home care and hospital care through our owned and affiliated hospitals - and community specialty care for almost anywhere someone may live in the Philadelphia region.
Still, though, at HUP we perform procedures and treat patients that have unusual conditions that only can be cared for at places like HUP. It remains the anchor hospital of our system and the only place that we provide high-tech critical care. And I think that's why HUP is recognized as one of the best hospitals in the country
Q. What is the history of your relationship with HUP?
A. I came to Penn in 1990 as a clinical scholar through the Robert Wood Johnson Foundation. It was at this time that I studied and did my work exploring health services research, cost-effectiveness analyses and quality assessment research. Then in January of 1992, I came over to HUP to start a program in outcomes assessment [evaluating the results of different courses of action] and quality management [using this data]. This was one of the first of its kind in an academic medical center.
A year later, in 1993, I became HUP's chief medical officer, which eventually led to my becoming the chief medical officer and chief quality officer of the Health System in 1996.
Q. And what's your background as a physician?
A. I'm a general internist. I try to maintain an active practice of general medicine. Before I came to Penn in 1990, I had completed a general medicine fellowship at the University of Pittsburgh.
Q. How do you juggle quality of care versus cost of care?
A. We don't try to juggle these issues. I believe the focus needs to be solely on quality and not on cost. I believe that those in health care whose sole objectives are to reduce costs have made a serious mistake. If you focus on quality, you simply strive to deliver the most appropriate care.
Sometimes this best-practice approach to care costs more and sometimes less than we currently expend on care.
Q. How has the dissolution of HUP's neighbor Allegheny affected the hospital?
A. Of course we were saddened to see so many of our colleagues' lives disrupted by the Allegheny bankruptcy. As difficult as this was, we worked to assure that the transition of patients and physicians who chose to leave their system and come to us was as smooth as possible.
In the end we were fortunate that many talented physicians decided to join us and have become very important contributors to our efforts to continuously build the best health system in the country.