DAVID T. FEINBERG, M.D., M.B.A., HAS A BUSINESS CARD BRIMMING WITH IMPORTANT TITLES. CEO of UCLA Hospital System. Associate vice chancellor for UCLA Health Sciences. And now, president of UCLA Health System, a position to which he was appointed in July 2011. But, says Dr. Feinberg, none of those labels mean very much to him.
"I don't really care for titles," he says. "I'm happy to have them on my business card, but in a lot of ways I still feel like I am a resident here at UCLA."
Dr. Feinberg and his wife Andrea arrived at UCLA in 1990 after packing everything they owned into a '74 Chevy Malibu and driving from Chicago to Los Angeles, where he would complete his residency in psychiatry and she would continue her training in pulmonary critical care. "I was just so proud to get into UCLA," Dr. Feinberg recalls. "And I still feel like that today."
Now as head of one of the most successful healthcare systems in the country — comprising more than 80 clinics and four hospitals that include Ronald Reagan UCLA Medical Center, Mattel Children's Hospital UCLA, Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA and UCLA Medical Center, Santa Monica — he still spends much of his day talking with patients and their families, learning from them what he can do to make their experience at UCLA better.
"So yes, I have big titles and this is a big place, but I really just feel like I'm one member of the team," he says. "And I'm as excited to be here today as when I came as a resident. I wish I could still have my title PG2 (post-graduate year two). I'd rather be called the PG2 then the president."
Whether as president or PG2, Dr. Feinberg spoke with UCLA Medicine editor David Greenwald about his new role.
You don't care for titles, but you are the president, and that is a position that is new to UCLA Health System. What does it mean for the system to have someone in that role?
David T. Feinberg: What I think is incredible is that for the first time, this position symbolizes that we have alignment between the two big parts of our clinical mission: the hospitals, or UCLA Hospital System, and the Faculty Practice Group. They are not separate from each other. Together they make up the whole of UCLA Health System, and they need to be aligned and working together for us to deliver at all levels of our organization the best healthcare available anywhere. When I speak with my colleagues from other hospital systems around the country, they talk about, "If we could just get the doctors to do what we say." That's never an issue here. Our doctors are leading what we're doing here. We are one group marching to the same drum beat or toward the same goal: to heal humankind one patient at a time, by alleviating suffering, promoting health and delivering acts of kindness. And we do that in whatever context it is that you, the patient, come to see us, whether that's at one of our more than 80 clinics throughout Southern California or at one of the four hospitals on our two campuses in Westwood and Santa Monica. What I am most proud of is that our organization is really obsessed with being patient centered, in making sure that whoever comes through our doors is treated like they are someone in our own family. That's our standard.
That is a standard that definitely has been set within the hospital system, and one that is attested to by the dramatically increased patient-satisfaction scores, up to 99 percent in some areas.
DTF: There is always room for improvement, whether it is on the hospital side of things or the community-offices side of things. Consider the hospitals, for example. It is wonderful to be in the 99th percentile in patient satisfaction, but what that means is that 85 out of 100 people would refer a friend or family member to us or rate us 9 or 10 on a scale of 1-to-10. When you look at it that way, it's not that great. Eighty-five out of 100 patients would refer to us, but 15 would not. So while we are proud to be in the 99th percentile, what that really means is we are the best in an industry that is not known for good customer service. When we get to 100 out of 100 patients who would refer to us, then I will be truly happy.
How do we bridge that gap to get to 100?
DTF: All that we accomplish here — our Nobel Prize winners, our organ transplants, our breakthrough medical research — really doesn't mean anything to the patient at the time he or she comes through our doors. The patient who comes to our Emergency Department tonight by helicopter doesn't care about that. That patient and family only care about what is going to happen to him or her. We are challenged every day to operate wholly in the present, to be focused on what is happening in the moment with that one patient we are treating. We've made great progress in that regard, but the journey is not over. There's still lots of room for improvement in our inpatient setting, and that is true for outpatient as well. We have plenty of work to do to make sure that every patient, without exception, receives the safest and highest-quality care in an environment that offers the highest level of compassion and respect in an ethically, culturally competent way.
Let's focus on the outpatient setting for a moment. What are some areas that you view as your first-tier challenges?
DTF: I want us to be able to say to the outside world, "UCLA is the best in healthcare and we're available." What does that mean? It means that not only are we available — that our specialty and subspeciality services have the capacity to see all the patients who want to come to us — but that we also respect you and we respect your time. So we need to have same-day appointments for everything. If you or a member of your family is told she has a lump in her breast, and you live in Bakersfield, you should be able to get in to see our cancer specialist within however long it takes you to drive in from Bakersfield. If you are a regular patient coming to see us, there needs to be a smartcard on the dashboard of your car that will alert the clinic you have arrived, so that a room is ready for you when you walk into the office. And when you enter the room, everything you need is there for you — the right doctor, the right support personnel, the right equipment. Everything is coordinated around you, the patient. Let's be honest, no one comes to see our specialists because they want to. Whether it's the hospital or an outpatient clinic, if someone comes to us for specialty care, it is because he or she is sick and often frightened. Whatever is going on, it is messing up their day, and we have to get the concept that for them this is a crisis. So it is our obligation to make this visit as efficient and as comfortable for them as possible, with the underlying message being that it is a privilege for us to care for our patients.
You used the word "capacity." Maintaining an appropriate level of capacity is a difficult challenge for a system that is so in demand. How do we achieve that?
DTF: Hospitals that have done well in this area would tell you that in the beginning of their journey, they didn't have the capacity. Virginia Mason Hospital and Medical Center in Seattle, for example, was planning a new outpatient building because they felt they had insufficient capacity. But what they soon realized was, it wasn't a matter of capacity. It was a matter of efficiency and of being more patient-centric in their approach. If they could get rid of waste within their system and make things run better, then they really didn't need a new building. By focusing on providing care to their patients from the moment they walk through the door, they were able to convert their waiting rooms to clinical space. So when we talk about issues of capacity, a lot of times it is because our systems are simply inefficient. If we can eliminate that inefficiency, the capacity expands incredibly.
Has that been demonstrated by anything we have done here at UCLA?
DTF: To some extent we have done it in the hospitals, where we take care of just over 700 patients who stay overnight. In these tertiary and quaternary care hospitals, the cases can be very complex, but often there wasn't real communication between the different providers taking care of the patients. We found that about 25 percent of the time, for example, nurses caring for a patient learned about that patient's discharge from the patient him- or herself. The communication wasn't happening in an efficient way. So now we have interdisciplinary rounds on every patient every day. The whole team gets together daily and discusses that case, and what we've found is that patients are getting out of the hospital sooner, and the rate of readmission has decreased. The quality of care has gotten better because it is more coordinated, and that has freed up capacity because patients are not staying as long or are not coming back. When we looked at the numbers recently, we found that over a six-month period, we took care of 800 more patients in the same buildings than we had in a previous six-month period. By getting more efficient, we created more capacity. Sometimes when we say we don't have capacity, that really is the case - we don't have the space or we don't have the staff to handle the demand. But I believe that most of the time it is because we are not particularly efficient in how we do things.
Let's talk about healthcare reform. Whatever happens in the courts with the Affordable Care Act, cost containment in healthcare is going to remain an issue. How do you see this evolving?
DTF: The current system of healthcare in the United States is based on volume. The more volume, the more you do of something, the more money you make. If you're a gastroenterologist and you do colonoscopies, the more you do, the more money you make. And the sicker patients are, the more the system rewards the physicians who take care of them. So a neurosurgeon doing complex procedures on very ill patients will make more money than a pediatrician doing well-baby checkups. The switch is going to be from a system where compensation is based on volume to a system that is based on value. And value is going to be defined as providing high-quality care for lower costs. So when the basic framework for our system is switched from an emphasis on taking care of really sick people and making them better to taking care of large populations of people and keeping them healthy, it will be a total paradigm change. And it makes sense. So right now, UCLA is the No. 1 organ-transplant hospital in the United States. That is wonderful; we save lives and perform miracles every day. But with this paradigm shift, I think we have to become the No. 1 leader in saving organs, in figuring out how to keep people with their current body parts, so to speak. We need to figure out how to be better about preventing diabetes, for example, and how to take people who have illnesses and keep them healthy and out of the hospital. Accomplishing that is high value for low cost, and so we have to start thinking about taking care of populations and not just individuals.
How are we positioned for this?
DTF: I think we are perfectly poised to do that. Unlike other academic medical centers, we have a few things going our way. We have this great alignment, which we have discussed. We have a large primary-care base for an academic medical center, so we already have hundreds of doctors on faculty who spend much of their time seeing outpatients. That allows us to take large populations, keep them healthy, and hopefully not have to use these complicated tertiary services that only the sickest of the sick get. It is a system that really makes more sense. Think about it - what do we want for ourselves and for our own families? We want to be kept well enough that our care could be delivered in outpatient settings, and we do not have to be admitted to the hospital. I want for my mom to be able to get all the preventive medicine she needs so she doesn't become ill in the first place. That's what I would pay for. That's what society should pay for. And if we can get to that as the fundamental approach of our healthcare system, it will drive down the cost of care. And we have really smart people here at UCLA who are interested in this question of health-services delivery and are working to figure out these new models.