Katrina Keefer Reflects on 2 Years As CEO of DCH, A Health System on the Rise

There are countless adages about the difficulty of turning around a sizable ship - the larger the vessel, the longer it takes to correct an errant course. And as the third-largest employer in Tuscaloosa County, there are few proverbial boats bigger than the DCH Health System, where CEO Katrina Keefer has been at the helm for more than two years.

In a November interview with the Tuscaloosa Thread, Keefer said DCH is finally headed in the right direction again, and she is excited to keep navigating the System in calmer waters in years to come.

The interview will be shared below in a question-and-answer format, with minimal edits for length and clarity.

Q: You first came on board in September 2022 and have served as CEO for more than two years now. Talk about your time here so far and the improvements the System has seen in that time.

Keefer: It's been great, overall, to see the change in culture, the boost in confidence in our caregivers, the pride our team takes in providing care and their engagement with each other, with our patients and their families. I'm so proud of the progressive, incremental steps taken to increase overall quality and patient safety scores, as evidenced by both of our hospitals being scored a "B", which is a 41 percent increase in our score from when I arrived. There is a lot of great energy around that, which demonstrates some of the hard work that the teams have done related to safety and patient experience.

I'm excited about improved metrics in the emergency department, which is our front door, and we're very clear about that. I'm really pleased with bringing down our turnover rates from a human resources standpoint. That's not just the overall rate and not just RNs, who everybody focuses on, but even our Environmental Services Workers - we've gone from a 30 percent turnover rate and we're holding under 15.

All of our metrics are continually improving and we certainly aren't where we need to be and I don't want to sound like I feel like we've arrived, but I do feel like when we put together plans and execute them in a thoughtful, structured, inclusive way, we get great results and our caregivers are proud.

So I've just been lucky to be sitting in my seat for the last two years and watch that. When you do all of those things, the improved financial results follow - it's also been fun to see those.

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Q: Let's talk about those Leapfrog Scores! Spring 2024 was DCH's first B ranking in eight years and you've maintained that going into the Fall. That follows a long streak of Cs and Ds. Has the patient experience increased that dramatically, have you focused more on scoring well on the tested categories, or is it a combination of the two?

Keefer: When I first arrived, I thought of Leapfrog as just a score, and as a hospital administrator, I had never really focused on that in any other market. When I got to Tuscaloosa and we were a D, I would try to tell people that's just one indicator, and I quickly realized that score is really important to Tuscaloosa.

Because we are a sole community provider, when the hospital industry was struggling, people saw DCH as failing. When they saw a Leapfrog D, to them, that verified their assumptions.

What we've tried to do is to realize Leapfrog is generally an open-book test. You've got to have fewer hospital-acquired infections, you've got to have better patient outcomes, and you've got to have all of these very specific things, so we know what we need to hit the score. But we've been very careful to take incremental, sustainable steps. If you just go chase the grade, you might get the grade one time, but then you've probably missed the steps to make sure it's sticky, that it all builds upon itself, and that you get better over time.

So, I'm not a "grade chaser," and I think it's more important that our teams come together and execute our plans and get the results, which do indicate - clearly - that we are taking better care of our patients.

Q: What were some of the most important steps to take to get that score up?

Keefer: I would say service excellence.

We have really trained our folks to not only understand how best to talk to patients and their families but also how to encourage caregivers to talk to each other.

Usually, when we have failed, it was because of a communication error, not a clinical error. So we want to make sure that our caregivers understand who they are.

If you have higher employee engagement, those employees take better care of patients. If they consistently work with the same team members - less turnover! - then they continue to build rapport and understand how they practice best together.

We've redesigned the way we greet our patients and their families. We understand that people are not at their best, normally, when they get here. We birth a lot of babies and that's a very happy time for a lot of people, but most people who come to us do not come at their best and we're really trying to prioritize how we receive them.

I also believe that we're scoring better because we've refocused and re-engaged on higher-acuity services, a lot of which has come through physician recruitment. A part of your Leapfrog score is demonstrating you have clinical competence and you perform enough of certain kinds of procedures to count.

So it's been multifaceted, but we're focusing on meeting people where they are and the consistency of the care given.

We also know a clean hospital means a lot to people - which is why I spend as much time or more time with my Environmental Services team than I do some of the other caregivers in our organization.

It's been an overall team effort.

Q: During our first interview as you settled into this office, you talked about prioritizing the emergency room - reducing "Wall Time" and how long it takes to get a patient in a bed who needs one. How have those numbers changed, which might not be reflected in a Leapfrog letter grade?

Keefer: The emergency room is a community hospital's front door and we have a new leader in that area who has worked with our analytics team to produce a scorecard every morning at 7:30. It shows exactly how many patients came into all three of our emergency departments, how long it took them to get to triage, how many minutes to intake, how many left without being seen.

We've seen our year-over-year patient volumes increase. Last year, we were about 10 percent over the prior year and we're projecting another 10 percent increase. We've gone from seeing 145 patients a day to about 170 at our Regional campus.

When I was hired, our Left-Without-Being-Seen rate was in the 9 to 12 percent range. It's less than 3 percent now, which is the target.

Our metrics are going in the right direction, but we look at it every single day. Every single patient, where did we miss?

[...]

We just decided we were going to be very transparent and we were going to escalate anything that needed to be escalated and we would address it together.

I think the other key to the emergency department has been being very intentional as we plan for staffing, growth and timing together so that we're prepared for surges when they occur.

At our Northport campus, we still are having trouble with getting too many mental health holds. We only have six beds for that, but one day last week we had 13 mental health patients who were held in the emergency department. That takes up space where we would normally be seeing acute care patients, but we can't just walk into the lobby and start making excuses.

So we still have these times when we're stubbing our own toes, sometimes that's our fault and sometimes not.

Q: An increase in patient volume can be a good thing, but it can spell financial trouble for a community hospital if too many are uninsured and can't pay for their care. Does the spike in patient volume mean loss or gain for DCH financially, or does it all break even?

K: Like everything else in healthcare, it depends! But generally about 25 percent of our emergency department patients are not covered by insurance or a government payer. The more volume we get, you get more of the good but you also get more of the bad, and those percentages have not materially changed.

We are picking up more of the insured volume, particularly from the Tuscaloosa area, and we get patients from most of West Alabama, even some into Mississippi.

If we could close the coverage gap, the cost of care for those 25 percent would be covered at least partially and offset what is still, overall, the $30 million cost of care for uncompensated patients across the health system.

But we still take a lot of pride in being a safety net hospital and caring for all.

Q: It was pretty clear when you were hired that there were internal and external expectations for you to improve the DCH System. Have the board of directors or some of those outside voices weighed in about the job so far?

K: Well, firstly, I appreciate the board giving me the opportunity to take on this challenge. On my first day, my search committee chair gave me a document that articulated the approach they expected of me very clearly.

Internally, I needed to build a transformative leadership team. I needed to assess the quality of care. I needed to understand what a viable financial model in a post-COVID world would look like, and I needed to address HR metrics to ensure that we had access to higher-quality caregivers and kept those pipelines open.

Externally, it was building relationships with the appointing authorities (the elected leaders in Tuscaloosa, Northport and Tuscaloosa County). It was building relationships with the medical staff. It was very clear that we needed to be a good partner outside of our own organization.

I feel like in all of those areas, we have made a lot of improvement. I don't think we're where we need to be on any of them just yet, but I do feel like I was uniquely qualified when I came in. My skillset and my toolkit really matched the challenges that were posed and I'm thrilled about how far we've come in all of those categories.

We have metrics that can demonstrate many of the things that are internally measured and report them in a much more structured way.

 And externally, this community has been so welcoming to me and allowed me to be very active in communicating our messages and commitments. Winning the Chamber's Distinct Service Award - it was such an honor to receive that after only being in the community for a short time.

Now what the board is challenging me to do is shift from "survival mode," get ourselves together and really shift to "strategic mode." They want to be very active in that process, thinking through and planning to do what we need to do to ensure this hospital can continue to anchor West Alabama for as long as any of us can see into the future.

Q: If it's not too forward - as you talk about the shift from survival mode to strategic mode, do you see yourself staying on as the CEO of the "strategic" DCH?

K:  I have spent way too much time and energy getting this place where we are right now to leave - we're about to start the fun part! We have so many new leaders in place, and so much good momentum and buy-in from the community. It has taken far too much blood, sweat, and tears to hang it up and start over doing that again somewhere else.

I love that I can be known professionally as a turn-around girl, but that takes a lot of energy. As our team has come together with the right people in place at the right time, we are all ready to accelerate the change that we've been able to start accomplishing together.

I'm here for as long as I wake up every day thinking that I am adding value to this organization, and I hope that's for many, many years to come. It's going to mean that I've got to keep up and do some hard and challenging things, but I am super excited about the future in Tuscaloosa, and I want to be here for a long time.

Q: You've talked about a new leadership team a few times. Can you go into some of those efforts and hires?

K: I'm so proud of the people who have chosen to join the team.

As we have looked at bringing people on board, we've focused on not hiring for the title but hiring for the team, whether that's the team of existing caregivers who a hire would be leading, whether it's their team of peers who they will be working with, whether they have a skill set or competency that complements the overall DCH team.

That's the only way you can have this many leaders join an organization in this amount of time without confusing the organization.

We've added rigor and structure so that people who have been at DCH a long time and new people alike will understand how to get things done.

Q: You're no stranger to the Deep South, but has anything surprised you about your time in Tuscaloosa?

K: I was genuinely surprised at how embraced I have been made to feel here by the community and business leaders, by our caregivers and caregiver spouses. When I'm out at a restaurant, people come up and tell me they're glad I'm here - that's been unique. People are nice in a lot of Southern towns but that welcome feeling differentiates Tuscaloosa.

I also maybe didn't realize the many benefits of living in a big college town. I've enjoyed joining the Opera Guild. I love football games and basketball and gymnastics and then there are all of these other benefits that come with the town, getting to go to all these student performances and the like - it feels kind of like living in New York City! There's always something to do.

Q: Is there anything you're most proud of in your tenure so far as CEO?

K: Getting that Leapfrog B rating for the second time means a lot because it represents so much intentional work, but also the budget we passed this year is $61 million better than the way Fiscal 2023 ended.

So demonstrating the improvement in the quality of patient experience while coupled with the financial piece - that makes me most proud.

Q: What has been the key to that financial growth?

K: Well you have to grow smartly - you've got to grow good volume.

We invested in new physicians and new subspecialists, in rebuilding neurosurgery, rebuilding vascular surgery, rebuilding medical oncology, and rebuilding infectious disease. We invested in the things we needed to right the ship and to also get people to believe again that we can perform highly competently in a high-acuity environment and also fixed the front door - the emergency department.

There have also been some contract renegotiations. It's important to insurance providers that DCH be in Tuscaloosa because otherwise, they've got to pay Birmingham rates. My financial background and understanding of the insurance market helped us navigate with our payers and at least begin to take steps to be fairly paid.

But you can't cut your way to profitability in healthcare, our budget has actually grown from under $600 million to right at $750 million this year.

Q: And that includes raises for all employees!

K: If you take good care of your caregivers, they take better care of your patients and the financials take care of themselves. Now, that sounds very simple but there's much more complex thought behind it.

What we're trying to do is look at details that have not been looked at for many years and allow our managers and directors to help us understand how to review their information, to tell us what doesn't seem right. That transparency helps them to help you on the financial side.

We were investing in travel nurses and spending so much money on them, then we realized if we could create an environment where people wanted to practice, whether that be physicians or nurses or respiratory therapists or Environmental Service workers or accountants, we would be better off long-term.

We took a little dip financially in '23 to give those raises, but we were very conscious about it and tracked metrics so if it wasn't working, we could back up and figure out how to pivot.

I appreciate the board's support of that recommendation so we could take a leap,
go with our gut and say 'I know that this is going to work.'

Luckily it has, and we want to continue to be able to invest in our people, continue to give merit raises and keep up with the market. That's going to be really important for us.

Q: Are there categories where you still see room for growth or improvement?

K: We need to get an A from Leapfrog. We need to hit a 6 percent cash-flow operating margin. And we're getting to all of those things, but what's next for me is figuring out primary care and women's services.

So many women's facilities in Alabama are not going to make it. Several of them have already publicized that they're not doing deliveries anymore.

I think there are great models of care where we can utilize existing assets and resources and telemedicine to provide great prenatal and postnatal care in rural communities and then allow them to come here to deliver, but we're going to have to really double down on space for that and on recruiting OBs.

And we need to bring additional primary care capacity into the community. We don't want to duplicate anything that others are doing, but we do need to augment them.

We've been very successful in recruiting so many physicians - 24 and 24 months - and that came after partnering with community physicians to understand where they were and how we could augment what they have.

I think we're going to have to do that with primary care providers in our region.

Q: What comes next? The completion of the parking deck?

K: I'm hopeful that I get it for my birthday on January 6th!

Q: Any final points you want to make?

I'm looking forward to leveraging the partnerships that have been forged over my first two years here as we think about solving really hard problems for our community and for West Alabama, whether it's mental health or primary care. How do we work with the University as they transition to experiential learning and ensure that we continue to be a learning-centered environment and bring students in? 

I'm excited about the future. I feel like there are so many excellent partnerships that are in place where we're all working hard to support the community from a health and safety standpoint.

As the community is beginning to rally around identifying potential solutions to problems, there are a lot of people who touch those things in this community. It's been really neat to see a packed room at a Chamber of Commerce event to talk about mental health and homeless issues in our community.

Editor's note: Many of Keefer's personal acknowledgments of individual DCH employees were cut from this piece to reduce its length.