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One of These Docs Is Doing Her Own Thing

And it’s working. Dr. Patricia Gabow’s remarkable turnaround of Denver Health has made it a national model for public hospitals. And it just may be a blueprint for health care in the United States.

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Right away, you notice the things everyone notices about her. You meet in her office and are struck by how tiny she is. She’s barely five feet tall. And she’s so—a fact’s a fact—adorable: short curly brown hair, big brown eyes, cheeks rosy as rose petals. And what a smile. She’s dressed in different fabrics and different shades of creamy colors, and smelling of…well, cream. Or maybe it’s that she looks so creamy you just think she smells creamy. Regardless, this much is certain: Sixty-seven-year-old Dr. Patricia Gabow exudes all of the toughness of the Boy Scout den mother who always does all the work for the kids struggling to earn their merit badges.

You think: This is who walked into the tower of power, the office of political giant Denver Mayor Wellington Webb, and walked out with control of Denver’s city hospital, the second-largest city agency? This is who took over that Denver General Hospital, best known for its “Knife-and-Gun-Club” ER and for hemorrhaging money, and changed all that to Denver Health, a nationally recognized model of a public hospital?

You hear her speak, or rather do your best to hear her speak, as her conversational voice is little more than a whisper. It’s more like parched breath, so raspy her words sound as if they’re forced through a windpipe of sandpaper. “Please, call me Patti,” she says. It sounds as if it causes Patti great pain to speak. No kidding, when she talks your instinct is to hug her and say, “It’s OK, don’t strain yourself. Let’s go get you a cup of tea with some honey.”

This is the voice that has dressed down macho surgeons? This is the voice that has been summoned to testify before the U.S. Congress as an expert on providing government-managed health care? This is one of President Obama’s most influential voices on Medicaid?

Next thing you know, she’s crying. She’s explaining that her father died not long ago, and her mother, showing signs of dementia, has been moved to Colorado from Pennsylvania, and so Gabow recently went back to her parents’ home to clean out the place before it went on the market. She went halfway across the country and did this herself because she didn’t want to risk losing family keepsakes, like the letters from her biological father, whom she never got to know, and…her eyes fill up.

This is who one Denver Health doctor says has “ice water in her veins”? This is the CEO who, in 1992, began leading the hospital out of a $38.9 million deficit and into the black? She did that while Denver Health provided some $4 billion—$4 billion!—in uncompensated care, including $380 million in uncompensated care in 2010 alone. This lady is that CEO?

You accompany her to a senior staff meeting; both of you squeeze into an elevator packed with hospital employees. Riding down, apropos of nothing other than the fact that it’s morning, she breaks the awkward elevator silence by saying: “My husband once asked me in the morning, ‘Are you gonna have an “A” day today?’?” Her voice still sounds strained, but no longer weak. Apparently amplified by some strategically invoked ability to project—not merely her voice, but all of who she is—there’s an oomph in her tone that snaps back shoulders, commands attention. “And I’d say, ‘Yes.’ And he’d say, ‘Well, how do you know?’ And I said, ‘Because I’m the one giving out the grades.’?” There’s a few prolonged seconds of silence, and then the elevator doors open and she walks off.

So, this staff meeting: It starts off looking like what you’d expect a super unexciting hospital staff meeting might look like. The mothership of Denver Health Medical Center is a 477-bed hospital that sits prominently on the corner of Speer Boulevard and Bannock Street. It’s comprised of several buildings spread over several blocks. On this day, in the basement of the hospital, in a large classroomlike room, some 80 doctors, nurses, and administrators are gathered. As Gabow’s staff mills about, filling all of the available seats and standing along the walls, she enters virtually unnoticed. She’s so small that in a crowd—a crowd of people who are tall enough for the big-kid rides at Elitch Gardens anyhow—she’s difficult to spot.

Where, where…. Oh, there she is.

She steps onto a raised platform and pops up behind the podium’s microphone—all creamy and smiley—and begins as if she’s picking up in the midst of an ongoing conversation. Still effortlessly harnessing that power of projection on display in the elevator moments earlier, she says, “I think some of you heard I was a secret shopper this week. I was in the ER.” Gabow explains that she’d been playing tennis with her husband. She almost never beats him. On that particular day, though, she was up 30–love, rushed the net, injured her knee, and fell to the ground. Gabow tells the room that as she lay on the court, her husband uttered what could have been a “marriage-ending comment: ‘See, I told you winning isn’t everything.’?”

The room cracks up. Gabow’s delivery, and the audience’s reaction—the knowing glances with raised eyebrows shared among her employees—makes clear that what made her anecdote so funny is that everyone who knows her knows that while her husband of 40 years was joking, good old, soft-spoken Hal Gabow was not entirely kidding. The humor was in the extreme understatement. Gabow is always rushing the net to win.

Why, she’s barely taken a breath after her opening ice-breaker when, stat-like, she starts talking about “Black Belts”—not the break-a-board-with-your-forehead kind of Black Belts, but rather cost-chopping Black Belts—and “Value Streams” and “Rapid Improvement Events” and “Lean” and the “Shingo Prize,” which, evidently, is some kind of prize awarded to especially efficient manufacturing operations. Gabow thinks Denver Health can be the first-ever hospital not only to enter, but also to win. None of this is the sort of talk you were expecting to hear in a hospital, let alone a public hospital.

Public hospitals are operated and funded by governments, and serve as communities’ safety-net health-care providers. These hospitals are the polar opposite of private, for-profit hospitals, where the policy is essentially no shirt, no shoes, no feeling in your extremities—no problem—we’ll make you better, provided, of course, you’ve got coverage or can otherwise pay up. According to the Colorado Hospital Association, 63 percent of Denver Health’s patients are on Medicare or Medicaid, and only 9 percent of the hospital’s patients have commercial health insurance. As Gabow puts it, “Not exactly the best business model.”

Of the nation’s nearly 5,000 hospitals, a full one-fifth of them are public, and many are so in debt they’re cutting services, closing, or their municipal owners are selling the hospitals to for-profit companies. The ever-increasing health-care costs, the rising number of uninsured patients (especially with the record number of unemployed), along with cuts in Medicare and Medicaid, have had a devastating effect. According to the American Hospital Association, between 2003 and 2008 the country lost 16 government-owned hospitals. Yet, despite the national trends, everything at Denver Health is relatively spectacular.

As Tom Nash, vice president of financial policy at the Colorado Hospital Association, told me, “Denver Health has national recognition for the things they do. The fact that they can turn a margin is a testament to the fact they are working as efficiently as possible. They are nationally renowned.” In fact, as Gabow points out to her staff in this morning’s meeting, there’s a reporter from SuperImportantHospital magazine roaming the halls to find out how they’ve been doing it. The answer has everything to do with Gabow and a whole lot to do with these Black Belts, Value Streams, and Rapid Improvement Events she’s talking about.

Whenever you hear about Denver Health, it’s almost always in news akin to these actual press snippets from last year (cue AM radio reporter voice): “Denver’s first homicide of 2010 took place at 3:11 a.m. at 1434 South Lipan St. Police were summoned to break up a fight and found a man who was not breathing. The victim, whose identity was not released, was taken to Denver Health Medical Center….” “The other driver was transported to Denver Health Medical Center for treatment of non-life-threatening injuries. He has been identified as Jose Nevarez-Coronado, 22. He was later arrested on suspicion of vehicular homicide, driving under the influence and….” “A second man, who police were calling a suspect in the homicide, walked into the emergency room at Denver Health Medical Center a short time later with a gunshot wound.…”

And so it’s always been. 1860: Honest Abe is president. It’s two years after the Pikes Peak Gold Rush—16 years before Colorado is officially a state—when Dr. John F. Hamilton and Dr. O.D. Cass open the first city hospital of Denver, the place a noble mess of good intentions from the start. Patients tend to be “bummers,” which means some variation of the ornery types who’d come to strike it rich, but who more often than yelling “Eureka!” ended up broke, drunk, and trying to fight or fornicate away their misery—and thereby ended up shot, stabbed, or otherwise torn asunder by syphilis.

In 1873, long after Dr. Hamilton had left to patch up Union soldiers in the Civil War, Dr. John Elsner persuaded Denver and Arapahoe county commissioners to fund the construction and operation of a new City Hospital at the location where its descendent Denver Health stands today. That newly erected hospital was still regarded as the “Poor House” or “Almshouse.” Even then, it was apparent that combining health care and politics was a bad prescription. Throughout the 1900s—and most pronounced under Mayor Benjamin Stapleton—Denver’s City Hospital, like so many city agencies in so many cities, became a municipal swamp of patronage and corruption. During the two decades Stapleton was in office, he infamously stacked the hospital decks for everyone from custodians on up.

So it went, for decades—until Mayor Wellington Webb was elected. It was 1991, and Denver General Hospital was hurting. All of the worst aspects of being a city agency were crippling the hospital’s performance. “We felt we were being constrained by the city,” says Dr. Ernest “Gene” Moore, who has been at the hospital since 1976 and is one of the most renowned trauma surgeons in the country. “Abiding the rules that the city had us operating under, I think all of us felt like we couldn’t function the way we needed to.

“For starters,” Moore says, “we were under the city’s civil service regulations. If you had a clerk on the floor or a secretary who was rude or didn’t do their job, you could never fire anybody. Endless appeals. It was like, once hired, on for life. We took on dead weight to the point it was ridiculous. Purchasing new equipment would take years. All of the bidding and committees downtown…. The City Manager of Health and Safety [who oversaw the hospital] wouldn’t have a clue.”

That first year of Webb’s administration, Denver General was operating at a $38 million deficit, and there was talk of it going under. Webb was determined to not let that happen. The first African-American mayor of Denver, Webb was born on the working-poor South Side of Chicago in the Cook County Hospital. He was a sickly kid with asthma so severe his parents sent him to Denver to live with his grandmother, and his grandmother took him to Denver General. As mayor, Webb would not forget what it was like to be among the city’s most vulnerable population and need a public hospital. On top of that, Webb wanted a legacy of having built things, like Denver International Airport, Coors Field, the Colorado Convention Center. He did not want to be remembered as the mayor who closed down the then 130-year-old public hospital.

And along came this little lady doctor at Denver General. She was relentlessly tugging on Webb’s pant leg and telling him he ought to give up control of the hospital. Just give it up. To her. Dr. Patti Gabow insisted she could not only save the hospital, but she could also make it a model public hospital.

She’d come to Colorado from Western Pennsylvania, by way of Greensburg, a mining town near Pittsburgh, and by way of a few stops that began with Florida and a father she never knew. Her dad was a U.S. Army Private First Class during World War II, stationed in Florida, which is where Gabow was born. Her dad was among the troops who pushed into Germany, and during the invasion, on March 20, 1945, he fell victim to a booby trap, and ultimately, a short time later, died from the injuries.

Only a few years ago, before her elderly mother’s mind began to fade, Gabow’s mom dug out letters her father had mailed from Germany. Gabow had never before seen the notes. She’s still not sure why her mom suddenly dusted them off. Gabow suspects it might be because her mother felt her mind going and wanted her daughter to see the letters with her before it was too late. “He wrote about the future,” Gabow says. “About how much he loved my mother and about how he couldn’t wait to see his baby girl.”

A war widow with a baby daughter, Gabow’s mother returned to Western Pennsylvania from the Sunshine State and married the man who became Gabow’s stepfather. Gabow describes her family as being “traditionally Italian”—both of her grandfathers were from Italy. In the 1950s, not too many girls from traditional Italian families in Coal Country talked about wanting to be a doctor, but her stepdad was supportive. He was so supportive he insisted she attend a local, all-girls Catholic college, Seton Hill, to ensure she would not be sidetracked by boys.

Gabow found a mentor at Seton Hill in Sister Marie Scott, who was the head of the biology department. Scott took Gabow to the marine biology lab in Woods Hole, Massachusetts, where the nun was also the first woman to sit on the board. During her two summer sessions at Woods Hole with Scott, Gabow learned about more than science. “To see this nun hike up her robe and tie it under the belt and wade out into the water to collect specimens,” Gabow says, “with all these men—all these high-powered scientists—I think it was a really good lesson: You don’t have to change who you are, what you are, what you believe. If you’re a woman, you can succeed in a man’s world.”

In 1965, when she enrolled at the University of Pennsylvania medical school, Gabow was one of only five girls in her class of 125. Shortly after graduating, in 1969, she signed on with the University of Colorado’s Health Sciences Center, and thereby joined the staff of Denver’s city hospital. There’s a long-standing arrangement between the University of Colorado School of Medicine and Denver Health, wherein the institutions share staff and expertise. Denver Health is a teaching hospital, and all of the full-time physicians on staff, at what was then still Denver General, are members of the CU med school faculty. So while conducting a renal medicine research study at CU, Gabow became the chief of the renal division at Denver General. She was the only woman in the hospital’s department of medicine.

For the better part of 15 years, Gabow ran what was then the nation’s largest patient study of polycystic kidney disease, a hereditary illness that causes painful cysts and enlarges kidneys. In 1981, however, she lifted her head from the research to consider something else: She was promoted to director of medical services. Ten years after she took on that management role, which oversaw things like the OR and ER, the hospital was looking for someone new to oversee the entire department of medicine, and Gabow got the job.

Dr. Frank Judson was one staff member not thrilled by the hire. Judson had attended medical school with Gabow at Penn, and he’d worked with her for more than two decades at the hospital. He thought she was an unlikely candidate for head of medicine. Because her research, and her career, had been so specific, Judson says, unlike an interdisciplinary area of medicine—such as his specialty, infectious disease—he believed she lacked a broad understanding of medical and hospital operations. “There was nothing,” Judson says, “about her at the time that would have foretold her rise.”

Naturally, Gabow didn’t see it that way. Like Sister Marie Scott, she felt quite comfortable wading into these waters. “I think being on the research side is important,” Gabow says. “It means I like to innovate. I like to find new ways of doing things. I like to ask questions: ‘Now, why are we doing this?’ ” As director of medical services, she began reviewing the hospital’s operations, which she knew were not going well.

During 1991, that first year of the Webb administration, it seemed like every time the nearly seven-foot-tall mayor turned around, there she was, with that smile that conveyed, Hey, remember that thing we talked about—you giving me Denver General? There was a precedent: In 1989, University of Colorado Hospital left the state system and became a self-managing not-for-profit. Gabow made her case to Webb, repeatedly, until one day he asked her, “Are you ever going to get off this?” And she replied, “As soon as you say ‘Yes.’?”

Webb was looking at that $38.9 million deficit, and although he was personally committed to the hospital, the politician in him might have considered Gabow for other reasons. If her plan worked, Webb would be remembered as a civic hero. If it tanked, well, hey, he’d tried something bold and new. In 1992, he appointed Gabow the manager of Denver Health and Hospitals, which meant she was now both the director of medicine and the hospital’s chief executive officer. If Webb had been looking for a way to give Gabow and her ways a trial run, this was a pretty smooth approach.

Gabow and her husband, Hal, have two children, and at the time of her appointment to CEO, her then teenage son asked his mom, “How are you taking a job for which you have absolutely no training?” Gabow gave her son the answer she’s given everyone who’s ever asked that question: “I looked at this job like I looked at patient care: You get problems, you need a diagnosis. Then you need a treatment plan. Then you need to monitor the treatment plan. And if the outcome isn’t what you want, you have to go back and change the diagnosis and change the treatment.”

Over the next two years, Gabow, working with her co-manager of business operations, Tom Moe, did some amazing institutional triage. By 1994, the hospital was operating with a $60 million surplus—a two-year turnaround of almost $100 million. Moe, now deceased, and Gabow streamlined the billing system, reducing the amount of time before a bill was paid from 150 days to half that; encouraged physicians to buy less expensive equipment; and generally held down expenses.

In 1994, Webb began supporting the idea of making the city hospital an independent “authority,” and that created the political momentum that helped persuade the Colorado Legislature to authorize independent status for Denver General. In 1996, the mayor took center stage at a press conference in which he announced Denver General was changing its name. Denver Health, he said, was more than a name change: It reflected the hospital’s new, clean bill of health.

It was toward the end of the second of Webb’s three terms as mayor, in 1997, that Gabow got her wish and Denver Health was officially recognized as an autonomous authority. It defined itself as a “public safety-net hospital for the city and county of Denver,” meaning its mission was still a city hospital mission, supported by government funds, and the mayor still had sway over the hospital board. But the hospital was now unfettered by the city’s civil service regulations and so much of the bureaucratic red tape. Where it mattered, the hospital honchos now made the decisions—which meant, in essence, that Gabow made the decisions.

The longer she was there, the better the hospital performed, financially and medically—yet with each year, Gabow felt like there was much more that could and should be done. “Even though we had new drugs, new technology, new buildings, all that stuff,” she says, “the core of the way we did things really was not different. This began to frustrate me. Try to think of almost anything else that’s really good that hasn’t changed in 40 years.” By 2003, Gabow decided that she really wanted “to blow this up and start up again.”

There were no bombs. Gabow’s idea of detonation was to hire an industrial engineer who’d never been in health care. She had him study and map hospital operations, everything from food service to trauma residents. (While on the floor, a trauma resident walked eight-and-a-half miles a day.) Every time the engineer brought Gabow a map, she couldn’t believe how the hospital did business. There were so many lines on the page it looked like spilled spaghetti. The hospital had been in the black every year since she’d taken over in full in 1994, but what those squiggly lines told her was that efficiency, and thereby profitability and patient care, could be improved.

Gabow brought together a group of advisers: executives from companies like FedEx, the Ritz-Carlton, and Global Health. Looking at FedEx, she was inspired by the efficiency; she came to believe that if Denver Health could track its patients as well as FedEx tracks its packages, well, that would be brilliant. From the management theories in general, Gabow extracted and promoted a philosophy she called “getting it right.” When it came to the “patient experience,” the five rights were: achieving the right physical environment (built for safety and quality, supporting the patients, their families, and hospital employees); the right people in the right jobs; the right communication and culture; the right rewards; and the right process. Yet she struggled with communicating to her staff that these were all interconnected, like pieces of a puzzle. From her discussions with the group of executive advisers, Gabow heard about the “Lean” production principles of Toyota, the Japanese automobile company. She researched the concept and thought this could be the unifying philosophy she’d been looking for.

The cornerstone of the “Lean” Toyota way is getting rid of waste from the customer perspective. In the Toyota world, waste is disrespectful to humanity because it squanders scarce resources, and waste is disrespectful to the individual because it adds work. Gabow added her own twist: Waste is disrespectful to her patients, she said, because it asks them to endure processes with no value. Gabow loved the Lean idea but had to figure out how to take something that had been a manufacturing tool and apply it to health care. And that’s when things got really interesting.

Gabow hired trainers to educate her senior staff on Lean principles. Senior staffers got about four hours, and select mid-level managers got two hours. In those sessions, the managers learned, among other things, that a “Value Stream” is any process required to deliver services or goods to the customer. They learned that, on average, some 60 to 95 percent of a Value Stream is waste. Incorporating training terminology, Gabow dubbed the folks who completed these sessions Black Belts. She then sent the Black Belts forth into the hospital with the mandate to rid waste from the Value Streams.

Gabow didn’t merely send the managers back into the hospital, their heads filled with corporate speak—so treat patients like packages?—and weighed down by a mandate to cut waste. Senior managers picked processes in Value Streams that could be improved—and apparently they could all be improved. Black Belts then led groups of eight to 10 employees, each group a mix of the lowest- to highest-ranking employees from various departments. And each group was expected to improve the process in the Value Stream—find the waste, cut the waste, and implement a new, refined process. These group tasks were dubbed Rapid Improvement Events (RIE). Why rapid? Because each of these projects was supposed to take place in five days.

One of the first Value Streams targeted, in June 2005, was surgery, and the first process to be addressed was the prevention of postoperative infections. One of the major causes of complications while a patient is in the hospital is infection. A patient comes into the hospital infection-free, gets an infection in the hospital, and gets sick or dies. This is not good—not good medicine or, considering the follow-up treatments and potential litigation, not good for business. And yet, in theory, these infections could so easily be prevented.

Hospital infections commonly occur during surgery, and one of the best ways to prevent them is to administer an antibiotic to the patient within one hour of the first surgical incision. For years, Denver Health had what was considered a high rate of surgical infections, which Gabow had been trying to fix. The hospital had so many committees on the topic, yet when it came to the percentage of time the drug was administered within that crucial one-hour period, the staff could never get above 70 percent.

So in the summer of 2005, one of the first RIE teams took on the nagging problem. The team included the medical director, the chief of infections, a nurse anesthetist, and two registered nurses. According to the RIE protocol, on Day 1, the group met in a conference room from 8 to 9:30 a.m., and discussed the existing process. Next, they went on a site visit, or a “waste walk,” meaning they studied the handling of a patient being transported to surgery. Finally, they reconvened in the conference room and mapped the existing process by sticking Post-it notes on a wall. Based on their observations during the waste walk, they marked each step that appeared to be unnecessary. A total of eight hours.

Day 2: The group met in the conference room and designed a new process. Eight hours. Day 3: The group returned to the site and orchestrated a few test runs of their redesigned process. At 4 p.m. the group gave the executive staff an update. Eight hours. Day 4: They refined and “standardized” the redesigned process. Day 5: Between 8 and 9 a.m., in the conference room, they gave a presentation to executive staff, including Gabow. Then, from 9 to 10 a.m. they trained employees on the new formally approved and standardized process. Two hours.

What that RIE team realized was that in the old, accepted way, the OR would call a nurse on the patient’s floor to notify them the patient was on deck for surgery and that the antibiotic ought to be administered. What would then frequently happen is the patient’s surgery would get delayed. Maybe another emergency took precedence. Or, the OR nurse would call too early. Or any number of glitches. Regardless, the simplest, most efficient process, as the RIE discovered, would be to have the anesthesiologist, not a nurse, administer the drug. After all, no matter what, that doctor is going to be with the patient one hour pre-op. The new process the RIE produced in a week, for a problem that had been occurring for years, improved the rate from 70 percent to almost 96 percent within a matter of months. Today, some five years later, the RIE-created process is still in place, only now with a 96 to 100 percent effective rate.

Between June 2005 and June 2010, 254 Rapid Improvement Events took place within Denver Health. Some 1,273 employees representing 220 departments participated. The Value Stream processes addressed included, oh, just about everything: physician billing, psych consults, address verification, physician credentialing, dialysis, cancer screenings, in-patient enrollment, and so on. All of which, thus far, has saved or otherwise benefitted Denver Health by at least $88 million.

Another noteworthy RIE impact: Gabow has also orchestrated a dramatic institutional expansion of Denver Health, and while the square footage has increased by more than 30 percent, its mechanical engineering supply costs—think light bulbs—have decreased from $1.2 million to $700,000. While the physical space has gotten bigger by one third, the costs to sustain and supply that expansion have gone down. And each of these RIEs, according to just about every measure of patient care, has dramatically improved Denver Health’s ratings. According to the University Health-System Consortium, which is a group of 112 medical centers and 256 affiliated hospitals—Denver Health’s peer group—Gabow’s shop has the “lowest observed mortality rate,” meaning, in short, Denver Health saves more lives. Considering the patient pool, this statistic is especially remarkable, and not just in hospital land.

That Shingo Prize that Gabow had talked about in that staff meeting is named after Shigeo Shingo. Regarded as an “engineering genius,” Shingo was one of the architects of the manufacturing policies that drive Toyota’s production system. And the prize in his name is a very big deal. It was established in 1988 “to be the standard of excellence to educate, assess and recognize organizations that achieve the highest level of world-class operational excellence around the globe.” The prize is administered by the Jon M. Huntsman School of Business at Utah State University, and is overseen by a board of governors that is a Who’s Who of CEOs. Gabow’s Denver Health was indeed the first heath-care provider to enter, and, almost as if she willed it so, was recognized earlier this year with a Bronze Shingo Prize.

Gabow’s odd-sounding voice is caused by something called spasmodic dysphonia. There are a few types of the disorder, but all of them are caused by involuntary movements, spasms, in the larynx. One of the possible treatments is Botox injections into the larynx, which Gabow undergoes every three to four months. Interestingly, the prevailing medical theory on spasmodic dysphonia is that it may be a neurogenic disorder, which means it has something to do with nerves. What’s more, the ultimate root cause may be psychogenic, which means the problem is all in one’s head.

Gabow will tell you she doesn’t remember exactly when or where her voice troubles started. It was sometime, she thinks, around the mid-’90s, which just happens to be right about the time she was talking Mayor Webb into turning over Denver General to her. She jokes away the topic of her voice by saying the condition provides for humorous ice-breakers when she gives presentations or speeches. She says it gives her the opportunity to compare herself to the breathless Marilyn Monroe.

You think: It’s just like Gabow to take a perceived weakness and make it a strength, not unlike what she’s done with Denver’s city hospital.

Dr. Joel S. Levine says Denver Health has become a nationally recognized hospital because of “Patti’s ability to speak despite her voice, to speak by her actions and what she’s been able to accomplish at the hospital.” Levine is on the board of Denver Health, and so you think, Well, of course he’s going to say what a miracle worker Gabow is. But what makes Levine’s take on Gabow especially noteworthy is that he is also a senior associate dean on the staff of University of Colorado School of Medicine, and on the staff of the University Hospital, which is one of Denver Health’s competitors.

“People look at what they’ve done in terms of quality and reorganization,” Levine says. “Denver Health is a city hospital, a safety-net hospital providing close to the best measurable care of university hospitals around the country, and that is remarkable. It’s not just Patti. But she is the one that enables the process. She has been able to aggregate people around her who believe the same thing. This is remarkable evidence that you can produce a very high quality of health care for less, but you have to have a very efficient system to do that. I think this is what’s engaging people around the country.”

Depending on the perspective, it’s also what’s driving or missing from the ongoing debate about President Obama’s health-care legislation. A Wall Street Journal article last summer didn’t just point out that the nation’s public hospital system is on life support, it also cited that reality as an example of why the health-care legislation may not be such a great idea: “Faced with mounting debt and looming costs from the new federal health-care law, many local governments are leaving the hospital business, shedding public facilities that can be the caregiver of last resort.”

The new health-care law requires hospitals to meet mandates in technology, accounting, and overall care and systems integration in order to qualify to care for Medicare and Medicaid patients, and to remain competitive for other government money. For already cash-strapped public hospitals reaching these mandates, this amounts to drastic and dramatic improvements, and, to read the Journal, is next to impossible. Presumably, then, more of these hospitals will vanish.

These facts resonate with critics of “Obamacare.” Among other objections, opponents of the legislation have maintained that government-run health care for everyone—which, they would say, this new law paves the way for—cannot work. The problem, they say, isn’t for-profit health insurance providers, hospitals, or pharmaceutical companies. Rather, the troubles are a mix of wasteful spending, poorly managed hospitals coupled with the fact that we’re a nation of supersizing smoker types, and a country, particularly in states like Colorado, dealing with an influx of uninsured non-U.S. citizens.

Republicans who refused to vote for the law last March, and who this past January voted (symbolically) to repeal it, say more government involvement, imposing mandates, will make it harder, not easier, to provide health care for the uninsured. Instead, we should empower the “free market” to fix things. Just look at the Journal article: If small governments have been having such a hard time managing public hospitals in the first place, why in the world would Americans turn to Washington, the biggest government of them all, expecting it to successfully reform the entire nation’s health-care system?

Gabow knows better than anyone that providing medical attention for the masses isn’t easy, that it’s going to take time. “What I tell everybody,” she says, “is we didn’t get health care screwed up in a year, and to think we’re going to fix it in a year is incredibly naive. But you have to start somewhere.” She believes the health-care legislation is a good start. She points out that one of the first RIEs at Denver Health didn’t work, and that it didn’t work because, simply put, it was too ambitious. The Value Stream was essentially the “Patient Experience,” everything that happens to a patient from the moment his or her experience with the hospital begins until it ends. What the group, what Gabow, what everyone at Denver Health realized was that by breaking the Patient Experience down into small RIEs…well, that made a difference. It was kind of like a microcosm of the nation’s health-care system.

It’s about time, and political will, and commitment, Gabow tells you. Why is there resistance to President Obama’s legislation? “Let me explain,” she says. “Health care is a $2 trillion industry. If it cost us what it costs the rest of the world, we would be a $1 trillion industry. Think about how many people’s pockets you’re going to get into if you really take $1 trillion out of the system. So guess why everybody doesn’t want [change]. People are making a lot of money off of the dysfunction. And this is the core of why the system needs to change.” m

Maximillian Potter is executive editor of 5280. E-mail him at [email protected].

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