UH president and CEO, and President Biden's new pick for undersecretary for health at the VA, Shereef Elnahal, MD, MBA, details the steps taken to improve the hospital's finances, quality, culture, and community trust.
When Shereef Elnahal, MD, MBA, joined University Hospital (UH) in 2019, the safety-net hospital was struggling.
Elnahal, who was recently nominated by President Joe Biden to serve as undersecretary for health for the Veterans Health Administration, became president and CEO of UH after New Jersey Gov. Phil Murphy signed an Executive Order to install a monitor in the organization following concerns around the hospital's quality of care and financial struggles.
The organization experienced margins in the red, a disconnect between leaders and the workforce, and distrust from a community that the organization had promised to support.
At that time, the hospital faced many challenges including:
- Operating at a $12 million loss
- Having an earnings before interest, depreciation, and amortization (EBITDA) of just over 2%
- Receiving a D from LeapFrog in quality after having received an F two grades prior
- A disconnect with the community
- A disconnect between the top management of the hospital and the workforce
Elnahal served as the commissioner of the New Jersey Department of Health until he took the reins of UH. Since Elnahal took the top leadership spot, there have been improvements in the hospital's finances, quality, culture, and community trust and engagement.
In a recent interview with HealthLeaders, Elnahal details the steps taken to move the hospital from a struggling to thriving institution.
Creating a strong culture and improving quality care delivery
Addressing the organization's workplace culture was the first action item Elnahal focused on when he joined UH.
"Reestablishing trust with the community was of course important, and that was at the tip of the spear of our priorities," he said. "But … I had to convince our own team and our own staff that we have their best interests in mind."
The key disconnect that he found was that the workforce needed an advocate to fight for them, and to fight for a better internal working structure, he said. He also needed to identify what the team at the top levels of the hospital needed to feel empowered and informed to address the needs of the frontline workers.
"The talent on this campus … have always wanted to do right by the patients in this community. That was one of the first things I discovered when I arrived here," he said.
After Elnahal took over as CEO of UH, he said the organization recruited Dr. William Holubek, who reinstituted quality improvement efforts in the hospital.
Holubek, along with the chief nursing officer, Dr. Carl Kirton, established what Elnahal calls a "Lean A3 Management System" for the hospital.
Part of the system included that every frontline worker, including clinical and non-clinical workers, engaged in meaningful daily huddles. This opened up communication between the workers and leadership so that the workers could openly share feedback and the leaders would share the organization's priorities and next steps.
"There was a two-way conversation happening for the first time in many places in the hospital around the safety of the care environment," Elnahal said.
"That cascaded up into tiered huddles to a level where senior leadership of the hospital attended a daily huddle every morning where they would hear all those problems that are surfacing from the frontline," he added.
Elnahal said that the organization addresses its problems by tackling them with critical thinking and breaking down the top contributors to those problems. Then key people are accountable for financial metrics and quality metrics, which they report to senior leadership.
"We've seen substantial improvement just by instituting those structural things, while at the same time coaching and guiding folks on how to implement [change,]" Elnahal said.
Through these efforts, UH improved the efficiency of its care delivery, and decreased its length of stay by 7.3%. Additionally, the organization improved quality measures of several common hospital acquired conditions, including reducing central line-associated bloodstream infections by 40.3%, reducing catheter-associated urinary tract infection by 47.1%, reducing C. difficile infection by 22.6%, and reducing surgical site infection by 86.2%.
Additionally, the hospital conducted a culture of safety survey in 2021, which showed substantial improvements in all arenas over the two years prior, he said.
Forbes also recognized UH as one of the Best Employers by State for 2021.
Elnahal said that the improvements seen are a team effort across the organization, including the executive team, the frontline staff, and the board.
"[The board members] have been very supportive," Elnahal said. "They've held us accountable on execution, which is exactly what a board relationship should be."
Related: Covid 'Decimated Our Staff' as the Pandemic Ravages Health Workers of Color
Creating community Trust
Along with building trust with its workforce, UH also needed to build back trust from the community it serves, which includes minority and underserved communities.
Elnahal saw a large disconnect between the organization and the community, potentially the biggest disconnect of the hospital's history.
"That means a lot because, frankly, The Newark Agreements rededicated this campus out to the community it serves," he said.
"I keep The Newark Agreements on my desk. It was negotiated during a different time of racial reckoning in this area. The events of George Floyd reconstituted a lot of those conversations and brought them to the forefront," he said.
"I knew that we had to do better on quality and patient safety, we had to do better financially to better sustain this hospital as a public asset going forward. But most importantly reestablishing that trust with the community as an important partner, that would not only serve with patient care, but also through jobs hiring and more procurement from the community, and better support to the community, overall," Elnahal added.
"As much as being present was important for our own staff, being present in the community was equally important," he said.
The engaged staff stepped up and volunteered to do community-based events with the hospital, he said.
"I recall an incredible visit to the Portuguese Cultural Center here in Newark. It's a social club that is in part based on soccer, but also in part based on being a critical pillar of community support. As a result of that engagement where I met leaders and met folks who have deep healthcare needs that weren't necessarily being met, we're going to have a Portuguese liaison, who is not only Portuguese speaking but also trained in all the things that a community health worker would need to know to advance the agenda," he said.
"Those things are so important because they not only are symbolic in the sense that you're actually there and you can do care, they allow you to circle back and deliver and execute on what's needed. And we delivered on so many other things since then."
Additionally, UH guided the community through the COVID-19 pandemic.
It was among the trial sites selected during the Moderna vaccine trial, based in a minority community. The hospital was also the first hospital to administer the vaccine to the public in New Jersey.
Leaders, including Elnahal, hospital physicians, and COVID experts conducted public forums to answer questions and educate the community, "to rebuild trust and maintain trust with the community on things like vaccination, but also therapeutics, restrictions, and other measures that were needed to reduce virus spread," he said.
"A lot of misinformation and mistrust can be tackled directly with direct engagement."
The hospital also sent vans out into the community to do mobile vaccinations. The organization has provided more than 47,000 vaccines to the community, bringing the number of fully vaccinated people to 24,000.
Financial and operational levels
UH also saw a large improvement in in financial performance since Elnahal joined.
In order to make those changes, the organization had to look at its revenue cycle from top to bottom to make sure the organization was being compensated for all care delivered, Elhanal said.
"This isn't to line the pockets of particular individuals; we're a not-for-profit organization. Every single dollar we've made we reinvested in the infrastructure and the capital needs of the campus," he said.
Investments made included upgrading equipment and buying new radiology equipment. The organization has also made a number of needed capital upgrades to the hospital campus, he said.
"The most important story behind our turn around financially is the fact that we can reinvest in more of our capital needs," Elnahal said.
After several years operating in the red, the organization went from operating at a $12 million loss to reporting a $48 million surplus in the last fiscal year, Elnahal said. The organization's EBITDA also grew 6% in that time.
The organization also focused on growth, including growing new service lines and partnerships.
"All of that paid off. We've seen many more discharges from our hospital than in the previous couple years. This fiscal year, we've seen more emergency room visits, but most importantly I've seen many more clinic visits, so we're engaging people in the community before they need to be hospitalized, which is telling," he said.
"We're competitive, we raised rates across the board with union contracts, So this financial boon did not come on the back of employees. We never had a reduction of workforce we've never had a furlough throughout the pandemic. It's important to mention that," he added.
With the increase in capital, the organization is also looking to build a new campus in 2022.
"This is something the community deserves, it's something that the community was promised when The Newark Agreements were signed and codified and written," Elnahal said. "It's another opportunity to build a nucleus here."
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Editor's Note: This story was updated on Thursday, March 10th.
“This is something the community deserves, it's something that the community was promised … It's another opportunity to build a nucleus here.”
— Shereef Elnahal, MD, MBA, CEO, University Hospital
Melanie Blackman is a contributing editor for strategy, marketing, and human resources at HealthLeaders, an HCPro brand.