Elaine Couture has been spearheading wellness initiatives during much of her career in health care, so perhaps it's no surprise that she has some beliefs that census-focused hospital system executives of earlier generations might have considered disconcerting.

"If I could deliver an ideal health care system, the hospital would be empty," says Couture, who recently took over as chief executive at Providence Health Care, the Inland Northwest's largest health-care system.

Her mindset appears to parallel, at least to a degree, the direction that the nonprofit Catholic-sponsored Providence network is heading as it puts greater emphasis on providing services outside the hospital setting.

The most tangible evidence of that shift is the $58 million medical center that Providence currently is developing at 16528 E. Desmet Court, in Spokane Valley, and that will expand greatly the outpatient services it provides there.

Providence says the project reflects the direction that health care is moving under the federal Affordable Care Act, with comprehensive outpatient centers—focusing on convenience and affordability—supplanting hospitals at the center of the medical system.

Also, in a sign of that shift, and in what years ago would have seemed an unlikely pairing, Providence and Group Health Cooperative disclosed earlier this year that they've begun collaborating on the development of urgent-care centers in the Spokane area.

The health care sector is in a transitional year as it prepares for broad implementation of the sweeping new health reform law in 2014, with many unknowns remaining about how it will evolve, but Couture is enthused about the changes to come.

"I like to look at it as being an exciting challenge," she says, adding, "It's about, how do we build this new health care system that really takes care of the public? I do think we have a mandate from the public."

Couture supports Obamacare, as the new law is known, saying, "The thing I like about it is it's very patient focused."

The Providence network here encompasses Sacred Heart Medical Center & Children's Hospital and Holy Family Hospital in Spokane, along with nine other hospitals and organizations, which altogether employ more than 7,000 people. Providence Physician Services, the physician division of Providence Health Care, includes more than 275 primary-care, specialty-care, and hospital-based medical providers serving patients throughout the region.

Providence is in improved shape financially—with its two biggest hospitals here running ahead of budget—as 2013 approaches, after having had "significant budget challenges coming into this year," Couture says.

The most recent employment information supplied to the Journal of Business for a largest employers list put Sacred Heart's total full-time employment at 3,010 as of Nov. 1, down from 3,138 a year earlier, and Holy Family's FTE count at 765, down from 843. Providence representatives say, though, that the network has increased employment in some of its organizations outside of the hospitals, so its overall employment is probably about the same or up slightly from a year ago.

After enduring some layoffs in recent years, the hospitals have their staffing levels at about where they need to be for now, Couture says. Providence doesn't expect to add a lot of employees next year, but neither does it anticipate any layoffs, she says.

As dwindling reimbursements create greater financial pressures, Providence is striving to respond partly by incorporating more lean-operating efficiencies, Couture says.

"We have really focused on that within the hospitals," she says.

Providence is budgeting for a slight dip in revenue growth next year, due partly to its planned systemwide implementation of a customized health records system developed by Wisconsin-based Epic Systems Corp. The technology will help Providence provide more cohesive patient-centered care, but it comes with a substantial learning curve that is expected to reduce productivity over the short term, Couture says.

She took over the network CEO's chair from Michael Wilson, who had been an executive with Providence's Spokane hospitals for 31 years. Wilson is retiring, but will remain involved with Providence leaders in an advisory role through 2013.

He announced his retirement to staff members this fall, telling them that carrying out long-term strategic plans necessitated having his replacement on board now to assure consistency in decision-making during this time of transition, a press release says.

Couture, who had been serving most recently as CEO for Sacred Heart and Holy Family, has worked in the health care sector for 35 years.

From relatively early in her career, which began in nursing, she says, "I expected to be a chief executive of hospitals, but I didn't expect to be a chief executive for a regional health care delivery system."

She lived in Chicago during her formative years and says she developed an interest in a possible career in health care while babysitting for a nurse.

"I think the thing I saw was she was able to have a family, have flexible hours, and was never out of work," Couture says.

Couture's family moved to Montana, where she earned a bachelor's degree in nursing from Montana State University, in Bozeman. During her senior year, while doing clinical studies at Billings Deaconess Hospital with a group of honors students, an administrator urged the students to consider working toward leadership roles in health care, she says, adding, "That's what really triggered it for me."

Beginning in 1977, Couture worked first as a bedside nurse and then nurse manager at St. Vincent Hospital & Health Center, in Billings, Mont., after which she founded and directed an occupational health and wellness program called LifeCare that she says grew to have 60,000 members statewide.

In 1987, an administrator who had worked at St. Vincent recruited her to come to Providence St. Mary Medical Center, in Walla Walla, where he wanted her to set up and oversee an occupational health and wellness program similar to the one at St. Vincent, which she did. That one was named TotalHealth, she says, and also grew quickly.

While at St. Mary, she was able to rise in leadership, including serving as chief nursing officer, while also earning a master's degree in business administration from Liberty University.

She became vice president of Sacred Heart in 2002, succeeding Mary Butler, who encouraged her to apply, and was promoted to chief operating officer three years later, also taking on responsibilities for Holy Family.

Couture says she has had opportunities over the course of her career to go to work for health care organizations that weren't faith-based operations, but decided that she preferred working in a mission-focused culture.

"I believe in catholic health care," she says, "and what that brings and means to a community."

In Providence capital projects in addition to Valley medical center, Sacred Heart is getting ready to open a new $18.6 million emergency department that's designed to cut waiting time for patients. Also, Holy Family started work last month on a $9.5 million expansion and remodel of the maternity center at its North Side campus.

Providence Health Care is part of Renton, Wash.-based Providence Health & Services, a Sisters of Providence-sponsored nonprofit ministry that's among the largest health care systems in the country. It affiliated this year with Swedish Health Systems, creating a combined scope of services that includes 32 hospitals, 350 physician clinics, and many health, educational, and other services. The health system employs more than 64,000 people across five states.