A report by veteran health care executive Judith Persichilli concludes University Hospital in Newark, the state’s only public hospital, needs a transformational leader, new vision and management team focused on quality improvement and safety.

The report by Persichilli, who was appointed by Health Commissioner Dr. Shereef Elnahal in July to review expenditures and assess the level of care provided at the 467-bed hospital, comes days after John Kastanis, the hospital’s president and CEO, said he was stepping down effective this Friday in the wake of controversy over the deaths of three premature infants that may have been caused by a bacterial infection in the neonatal intensive care unit.

According to the report, in the five years since University Hospital separated from the former University of Medicine and Dentistry, the hospital “has not leveraged its unique position to focus on developing a culture of high performance.’’

An executive order signed by Gov. Phil Murphy directed the appointment of a monitor after the hospital received a failing grade on quality of care from nonprofit watchdog The Leapfrog Group; had its bond rating downgraded four notches due to financial difficulties; and attempted to reduce the number of pediatric beds without state approval.

Five overarching themes are outlined in the 30-page report to explain the hospital’s performance issues: The need for a transformational leader focused on creating a vision and building teams to execute the changes necessary to be a high-performance organization; absence of a strategic plan as a foundation for a shared vision and alignment on critical goals and objectives; an organizational culture not focused on a relentless pursuit of excellence; board oversight not focused on holding leadership accountable for underperformance; and inconsistent leadership due to turnover resulting in a lack of alignment on strategy and performance objective.

Among other recommendations and findings made in the report include:

• Develop a strategic plan and medical staff development plan;
• Make the hospital’s board representative of the community;
• Hospital board must hold the CEO and executive team accountable for quality/safety outcomes;
• Recommit to the Community Oversight Board and solicit its input on significant issues/actions under consideration such as changes in services/staffing;
• Hospital executive and management team needs to embrace a benchmarking system as a management tool to maintain and enhance staffing and productivity levels;
• Engage emergency department consulting specialists to do a complete review of the emergency room;
• Consider opening an urgent care center on site to relieve ER overcrowding. The ED is crowded with 80,000 visits annually, in addition to 3,000 patients treated in the Level 1 Trauma unit of the ED;
• Develop community engagement activities that support the hospital’s mission in Newark and provide a forum for partnership with the city; and
• If regulatory compliance and financial and quality performance does not improve, consider placing a full-time Department of Health representative at the hospital.

“I want to see the state’s only public hospital succeed for the patients who need care, for the broader community in Newark and for the frontline clinicians and employees who strive to provide the highest quality care every day,” Elnahal said in a statement.

While conducting interviews for the assessment, Persichilli said she met “many board members, medical staff, executive team members, stakeholders and employees of University Hospital who are dedicated to the mission and embrace the trust invested in them to care for the most vulnerable of the community with the highest possible standards. It appears that the front-line caregivers and employees are using techniques and processes to improve care at all levels.”

She also said it is imperative the hospital “improve quality outcomes and finances to position itself to be a worthy partner with the community and other organizations such as Newark Beth Israel Medical Center.”

The report notes University Hospital is “an indispensable asset to the vulnerable populations of Newark and the surrounding community,” serving 17,000 inpatients and 250,000 outpatients in its campus-based clinics each year.

It employs 3,300 staff and has a $670 million budget. Two-thirds of its patient revenues are Medicaid, charity care or self-pay, giving it the lowest percentage of commercially insured patients in the state. It is a Level 1 Trauma Center and is one of only two hospitals in the state performing liver transplants.

The hospital receives more than $150 million a year from the state for charity care, graduate medical education, mental health and reimbursement for employee pension expenses and fringe benefits.