Some Themes Emerge from the Problems at the University of California

Several recent reports help our understanding of the recent problems at the University of California - Irvine (UCI) medical center, and more broadly, in the University of California (UC) system. (See recent posts on UC here, and here, and on UCI here.)

The Los Angeles Times reported that "UC Irvine is beginning program-by-program reviews of its medical center, hiring consultants and launching its search for top health care officials, recommendations made by a panel of outside experts that reviewed the university's troubled medical programs." The new Chancellor, Michael V Drake, reiterated, "there was a 'failure of leadership and accountability' and poor oversight." Concretely, UCI is starting searches for a vice chancellor for health affairs and for a health care ombudsman "to make it easier for faculty and staff at the hospital to report problems. An interim ombudsman is working part time."

Perhaps some impetus will be added to these efforts by reports that the US Federal Bureau of Investigation (FBI) is investigating UCI ( also per the LA Times.) Meanwhile, the Ocean County Register published a long review of events at UCI. It first noted, "The residue for UCI is a hospital with a damaged reputation and low morale." David Magnus of the Stanford Center for Biomedical Ethics commented, "When you get that many problems, that speaks to a problem of institutional culture. There needs to be a pretty dramatic overhaul of that culture to proceed in an ethical fashion."

The history leading to the current problems was telling.

Until the early 1990s, UCI Medical Center's primary mission was to be the hospital that served Orange County's neediest residents. That was both a practical and historical remnant of a hospital that was founded in 1912 as Orange County Hospital and Poor Farm.

'Its image remained steeped in its history as Orange County's 'hospital of last resort.' Back then, a dedicated but underappreciated faculty and staff provided care exclusively for the county's poor and underserved in a tired and drab facility.' [said former CEO Ralph Cygan]
The nation's adoption of managed care as a medical-industry standard in the early 1990s threw UCI Medical Center and other hospitals into financial and operating crisis. For a time, UC officials considered leasing or selling UCI Medical Center to a private company.

That plan was abandoned in 1997. But all UC medical centers (including UC San Diego, UC Davis and UCLA) were ordered to bring in more middle-class patients with private insurance, reducing the hospital's reliance on government payouts for indigent patients.

Partly as a way to maintain its role serving the county's poorest residents, UCI worked to develop other ways to bring in more income.

In 1999, UCI spent six months drafting a new strategic plan for the medical school and hospital that sought to increase market share and research funding, and improve medical education, yet also cut costs. The new strategy called for UCI to start investing in "high-profile clinical programs with high potential for market impact, return on investment" and referrals.

Yet, while the hospital has rapidly expanded from a small operation into a giant, multi-tentacled enterprise, questions have arisen about whether oversight has kept up with growth.

Meanwhile, the San Francisco Chronicle reported the assessment of a task force on how UC compensated its leadership across the system. It concluded, "The recent disclosures ... lead (us) to conclude that, at least as regards compensation, neither the executives who lead the university nor the regents who oversee it have done all they could or should to fulfill their respective or shared responsibilities." Former state Assembly Speaker Robert Hertzberg, co-chair of the task force, said, "In this competitive environment where you want to bring in the best and the brightest, there was just a breakdown in terms of full disclosure. But it was a significant breakdown."

Putting this all together, there seem to be some themes:

• A leadership culture that "lacked accountability" seemed to be a problem across the UC system, and at UCI in particular.
• Despite demoralization induced by this leadership culture, faculty, physicians, staff, and students generally tried to do their best in trying circumstance.
• The leadership culture may have to some extent derived from a broad impetus within society to push not-for-profit, academic institutions to "compete."
• Making things better will require major improvements in leaderships' accountabilty and transparency.

These are familiar themes on Health Care Renewal.