Turkal applies doctor’s approach to running Aurora

Even though he is now the chief executive officer of the largest health care provider in the state, Dr. Nick Turkal, a family practice physician, still finds time to care for his patients. But now, as CEO, he is responsible for taking care of all of Aurora Health Care’s patients. In October, Turkal succeeded Ed Howe, who retired. Previously, Turkal was the metro Milwaukee regional president for Aurora. Turkal says he takes a similar approach to solving problems for Aurora as he does to solving problems for his patients. He listens to as many different opinions as possible, carefully considers the alternatives and then decides which remedy to administer. Small Business Times managing editor Andrew Weiland recently spoke with Turkal about several issues facing Aurora and the Milwaukee-area health care marketplace. The following are excerpts from that interview.

Turkal: “We’ve had a really great transition. I’ve spent the bulk of that six-month period doing listening sessions with our employees, physicians and with business and community leaders. To really go out and hear how people are feeling about working for Aurora, receiving care from Aurora, practicing at Aurora. It’s really been a wonderful process. I’ve been part of the system and part of this community for 20 years. But the ability to go out and listen in a new way to people who are out there on the front lines or making business decisions has been very, very helpful to me.”

Turkal: “Ed was a great mentor to me. He taught me a lot about the health care industry, particularly about the ability to have a long-term vision as to where the market is going. Our day-to-day styles are probably somewhat different. I draw heavily on my background as a family physician. As a family physician, I have really been a generalist. So, each day a primary care doctor faces a number of different problems. You spend a good part of your time listening and you work on diagnosing, and you try to work together with someone to figure out the answer. My administrative approach is very similar to my approach as a family doctor. So, it’s really an opportunity to say if those skills work well to solve problems with patients we can work with them well to solve problems for the health care industry. That key part about listening is very important to me because the answer to many things lies in first listening and assessing the situation. I’m very comfortable with decision making and enjoy the opportunity to take care of a broader set of patients.”

Turkal: “I hope to be in this role a number of years, and the thing that I will feel good about when I finish is that we are doing all of the right things at Aurora to make sure the population of eastern Wisconsin is healthier when we finish our work than when we started our work. And that’s why we work so hard at providing care in an integrated fashion. It’s why we’ve invested so much in information systems and certain technology. It’s about using the tools to really, really improve the care of patients in some dramatic ways.”

Turkal: “I’m pretty much of a looking forward leader. At this point, I’m very much looking forward to the place opening. For our patients, we take care of around 40,000 people in Waukesha County, we have been out of space for some time, in terms of our work at the (Wilkinson) clinic and having to have our cancer center at a different site. And then, of course not being able to provide the full continuum of care. So, I’m very anxious to get that hospital open. I think the people of the community are going to love the type of care we provide there.”

Turkal: “We’ve been pretty clear in the last decade or so about our geography. Our geography really is the eastern third of Wisconsin. As we look at Wisconsin as a state, there are 5.2 million individuals living here and somewhere around 3 million live in our service area. So, we’ve tried very much to say we’ve got access at the appropriate points up and down the (Lake Michigan) coast for people. We’re going to continue to look at how well we’re serving communities and whether we need to add spots. We always get asked about building hospitals, but really most of what we’ve built has been outpatient sites and pharmacies and the other parts of health care. Only a third of what we do is inpatient hospital care. Two-thirds of the care we provide is in other settings. That means physician offices, outpatient surgical centers, pharmacies, visiting nurse association. Those places are where the bulk of care is provided. Our ability to link them to our hospitals is what has helped us to get to a better value. By value. I mean a combination of quality, good service and cost. Over time we will continue to add some offices to certain communities. We will reassess our hospitals and where we have beds. We have replacement hospitals that we know we are going to have to face in the next decade or so, places like Sheboygan that are very, very old, simply not as efficient to run as a new place that we put up. So, yes there will be more building. It will be at a much slower rate than what people have seen over the last 10 years, because our strategy was really to get access to the people in the communities.”

Turkal: “We’re absolutely committed to Aurora Sinai. It is the last remaining downtown hospital. And we’re going to keep it there. We’ve actually done quite a lot of building on that site in the last 10 years, as we brought together the Mt. Sinai and Good Samaritan campuses. We have really very good facilities at Aurora Sinai. So, we’ve invested in the bricks and mortar, as we’ve needed to. But, more importantly it is always about the people and the programs. So, we have a world class Parkinson’s (disease) program at Aurora Sinai. We have a wonderful geriatric institute where we take care of particularly frail elderly patients. We have a fantastic team of breast care surgeons, radiation therapists and medical oncologists at Aurora Sinai. So, Aurora Sinai is really a vibrant place. We have done many things to improve the buildings in the last decade. We have done a lot of work on making sure that the service is tremendous. We think that is a place that is going to continue to grow and be healthy and do well. Given its location, we are always going to have some economic challenges. And that’s OK, that’s one of the reasons that we are a system so that we can continue to provide care there even if we can’t make it as financially viable as some other spots.”

Turkal: “We are, I believe, in one of the most interesting times for the health care market in the greater Milwaukee area, because there is so much shifting going on. The proposed merger between Froedtert and Columbia St. Mary’s, their whole strategy is about integrated care. That is the strategy that Aurora has been pursuing for a number of years and now to a great extent has achieved. So, we see it in many ways as an endorsement of what we believe to be true about integrated care.”

Turkal: “When they talk about integrated care, at least in the initial articles, they talked about not reproducing services at all sites. So if you look at Aurora, we focus our cardiovascular care and our transplant program at Aurora St. Luke’s. We focus our women’s program at West Allis and at Aurora Sinai.”

Turkal: “Less duplication of clinical services. For us, very importantly, better purchasing power. From a supply chain management perspective, we can purchase many things at a lower cost because of the size of our organization. If Columbia St. Mary’s and Froedtert can achieve those things, then that will be good for our community.”

Turkal: “Yes, if they’re successful, it could result in lower costs, and that’s one of their stated objectives. If they come together and they are a strong competitor, that’s fine with me. I like competition. I believe competition around quality and the best service is extraordinarily important in health care. And there is now such clear data (which shows), that if you truly improve quality, cost comes down. I think our business leaders are just now beginning to understand that if we compete on quality, then cost comes down. So competition in health care is good, but it has to be competing around quality. That’s what’s going to drive costs down. And, I will just say, from Aurora’s perspective, the reason that two-thirds of what we do is outside of the hospital is that the hospital is the most expensive site to deliver care. So, anything we can move into the community setting is going to be able to be done at a lower cost. So, the feedback now from insurers and insurance brokers is we’re the best value in town. I understand that several years ago everyone pointed at Aurora Health Care around cost, but our investment in certain types of technology, like electronic medical records and electronic ICU, our investment in quality programs that are measurable, those things have really allowed us to drive costs in the right direction, and that’s downward.”

Turkal: “There is no doubt that health care providers, including Aurora, have something to do with the high cost of health care. But what’s more important from my perspective is where are we today and where are we going? For the last five years at Aurora, we have been working feverishly at taking costs down. We’ve done that in a whole host of ways. First of all we’re using the Lean and Six Sigma approaches to processes. So, like many other industries, we’re finding that if we can streamline certain processes we can reduce the cost as well.

Secondly, as I mentioned earlier, is around supply chain management. That as we achieved a certain size, our ability to buy cardiac stents, orthopedic implants and paper and pens and all of those things, just the volume of purchases has allowed us to get a better unit price on those. That means we’re helping to decrease the overall cost of care. We’ve done a number of things with our employees around productivity, standards and expectations that have taken cost out of the system. We have not reproduced clinical programs at multiple sites, so that we focus them at one site and do them extraordinarily well. For example, the cyber knife, which I like to tell a story about, is an extraordinary piece of equipment that delivers a very high dose of radiation to tumors or abnormal blood vessels in the brain, in the chest, other places. It’s essentially a radio therapy version of doing the surgery without cutting the skin. So our first patient that was treated with a cyber knife had a brain tumor. He had treatment. Afterwards, our staff saw him across the street at Starbucks having coffee and reading the paper. He goes home, he goes to work the next day. Previously, that would have been open surgery, days in the ICU, rehabilitation. It’s a matter of applying technology to areas where it really helps a patient, and takes costs down. That’s an example of that.

Now, here’s the trick. We don’t need 15 cyber knives across Aurora. We don’t need 15 cyber knives across Milwaukee. We probably only need one. That’s a very important part of saying, let’s not have a technology arms race. Let’s use technology where we know it can help patients, and we know it can bring costs down in health care. If you look at our rate increases compared to our competitors, we have consistently for the last, four, five, six years, stayed below the medical CPI. We have been committed around this cost issue for a number of years and we are now at a point that we are seeing some very nice results. But it does have to be all of those things. Not just quality, it’s also plain good management of our resources.”

Turkal: “I believe (the hospital near Oconomowoc) will drive health care costs down in Waukesha County for the reasons that I have told you. This integrated care is so important. It’s that integrated approach across the different parts of health care that has allowed us to bring costs down. That’s going to be marvelous for Waukesha County. And I truly do believe in this idea of competition. If you compete based on really great quality and service, then the patient is going to win in the end. The other thing I would say about the beds and the amount of buildings, a couple of comments. Eventually (health care providers) have to replace beds. Buildings get old, they get inefficient to run. If you look around Milwaukee at some of the projects going on right now, the other health care providers are spending a whole lot more right now than we are spending on building projects. Some of that is replacement, and that needs to be done, ultimately. Some people are adding beds to their current sites. We have taken the approach that we are going to put beds where beds need to go. So, in addition to the building that everyone has seen during the last decade we have taken 800 hospital beds out of circulation. If they are not in the right place, you shouldn’t have them. So we’re not building places that are bigger than they need to be and if places do not have the right amount of beds, then we don’t keep them all.”

Turkal: “It’s been a variety of places. St. Luke’s South Shore, we are not utilizing all of our beds. Valley View Hospital in Plymouth, which was controversial to the community when the hospital closed, but it had an average daily census of about two patients. You can’t do high-quality cost affective care without an adequate number of inpatients. So we closed that facility and instead we have there a really beautiful clinic so that we can provide virtually all of the services that the community needs and if they need to be in the hospital then they should be in a place where we are doing a lot of hospital work, like Sheboygan. We probably build hospitals different than other people. We’re not loading everything into the hospital setting. We’ve continued to push many things out into our medical group settings or pharmacy settings, trying to make it easy access for patients. We’re going to right-size our hospitals and we’re going to do it by pushing things out into the community whenever we can and making it as convenient as possible for patients.”

Turkal: “We have one major gap in the geography of eastern Wisconsin that we serve, and that is the northern part of Milwaukee and southern part of Ozaukee County. It makes absolute wonderful sense for us to talk to a group that’s there already, rather than try to go in and reproduce physician services that already exist in a very high quality fashion. Advanced Healthcare is very interested in the same things that we are as we look at our strategic plans. They are very interested in high quality, good service and cost-effective care. We have good philosophical reasons to talk. We have good geographical reasons to talk. We’re very happy to be talking to them. I would love to see Aurora and Advanced come together in some fashion.”

Dr. Nick Turkal

Title: Chief executive officer of Aurora Health Care
Age: 51
City of residence: Whitefish Bay
Family: wife, Kathy; four children, Annie, 22, Lizzy, 18, Steve, 16, and Maggie, 11.
Hobbies/interests: Outdoor sports, running, jogging, Civil War history.