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The Cleveland Clinic Way
LESSONS IN EXCELLENCE FROM ONE OF THE WORLD'S LEADING HEALTH CARE ORGANIZATIONS
By Toby Cosgrove
McGraw-Hill EducationCopyright © 2014 Toby Cosgrove
All rights reserved.
Group Practices Provide Better—and Cheaper—Care
Winter in Cleveland can be beautiful when the air is crisp and the evergreens are cloaked in white. But by mid-March, with its bare trees and gray skies, a longing for something more alive fills the air. Against this backdrop, Lisa Cantwell, a woman in her thirties, saw her doctor for a prenatal ultrasound. Already the mother of two young children, she had been through prenatal testing before. But nothing could have prepared her for the ordeal that she and her husband, Josh, were about to face.
The ultrasound, performed at 18 weeks, showed something in the baby's neck—a dark mass, six centimeters across. In 35 years, Lisa's prenatal specialist had never seen anything like it.
Several follow-up scans that spring and summer revealed that the cyst was growing. Lisa's caregivers were concerned that the cyst would impair the baby's ability to breathe. Her case was transferred from Cleveland Clinic's community hospital to the main campus, which handles the most serious medical cases. Mother and child were admitted to the Fetal Care Center, where a multidisciplinary team of obstetricians, neonatologists, and pediatric subspecialists would provide care. The center is not a place but a virtual team linked by purpose, protocols, and electronic medical records.
When the time came for Lisa to give birth, Dr. Paul Krakowitz, a leading pediatric head and neck surgeon, discovered that the mass was just under the baby's windpipe. The baby might not be able to breathe outside the uterus. Cutting the umbilical cord could prove fatal.
Dr. Krakowitz's team used a rare procedure. Two operating rooms were prepared side by side. Surgeons waited in the second room, ready to operate on the baby if needed. In the first room, Lisa had a normal cesarean, but the baby was lifted only partially out of the uterus. Before full birth, Dr. Krakowitz performed an endoscopy to see whether the baby's windpipe was clear. It was. Baby Dominic was fully delivered and sent to the Neonatal Intensive Care Unit.
To the naked eye, the baby's neck looked perfectly normal, but the cyst was under the skin—and growing. It was a cystic hygroma, a large sac filled with fluid. Once they were home, Lisa carefully monitored Dominic to ensure that the cyst didn't impede his breathing. Almost every day, she checked in by phone with the nurse who ran the Fetal Care Center. But in the second week, Lisa noticed that Dominic was turning blue. The cyst had grown so big that it was strangling her son.
Lisa and Josh rushed Dominic to Cleveland Clinic's Emergency Department. Doctors intubated Dominic to open his airway, and Dr. Krakowitz prepared to operate. The next day, he removed a cyst running from the left lobe of the thyroid into the cervical spine, up through the thyroid cartilage, and into one of the tubes that connect the nasal cavity to the ears. These structures are tiny in a two-week-old infant, and the cranial nerves that control hearing and speech run through them. Bleeding had to be controlled because babies don't have much blood to begin with. The operation, which took 4 ½ hours, was a success. Dominic was moved to the Pediatric Intensive Care Unit, where additional medical specialists and highly trained nurses stabilized him. He was on the road to recovery and a normal life.
How Doctors Are Organized Matters
No single person saved Dominic's life. His survival lay in the hands of many caregivers—highly skilled specialists who included radiologists, otolaryngologists, neonatologists, obstetricians, anesthesiologists, nurses, and technicians. The caregivers who treated Dominic were an integrated group, with each function supporting every other function. Every circuit was connected, from the top medical specialist to the nurses to the blue-scrubs team that disinfected the operating rooms. Like any tightly knit team in the corporate world, Dominic's caregivers all wore the same logo, reported up the same organizational chart, and had the same signature on their paychecks. They also had the same mission: to save lives, put patients first, and advance the cause of health and medicine. And as members of a group practice, they had the protection of quality and safety protocols, cost efficiencies in purchasing, and a commitment to innovation and process improvement.
For all the talk about America's healthcare "system," it's not a system at all. There are about 800,000 doctors in the United States. Some of these doctors are self-employed. Some work for hospitals. Many work in practices of fewer than 20 colleagues. As of 2012, about 40 percent were truly independent. This small-scale, cottage-industry approach can deliver finely crafted services, but the quality of those services is variable, and costs are typically high. Coordination, standardization, quality improvement, and all the other factors that today make high-quality products and services available to more people more rapidly and more cheaply than at any other time in history have yet to be generally implemented in healthcare.
However, the same strategies that have revolutionized every industry from textile manufacturing to farming over the past 250 years can be applied to healthcare. The first step is to organize doctors differently—to bring them together to form much larger organizations led by doctors, not professional managers.
In 2005, only 4.5 percent of American doctors worked in group practices of 50 or more. But this is rapidly changing. More of American healthcare undoubtedly will shift to the group practice model embraced by the Mayo Clinic, the Cleveland Clinic, Kaiser Permanente (California), and similar organizations. We will probably see more and more groupings of hundreds, even thousands, of physicians. These groups invariably will—and should—embrace a corporate model, paying doctors a salary, tying continued employment and raises to annual performance reviews, and leveraging their size to buy high-quality equipment and supplies more cheaply.
Origins of the Group Practice Model and Cleveland Clinic
The group practice model was essentially born in the midwestern United States. The first nonprofit group practice was established by William and Charlie Mayo in Rochester, Minnesota, more than 100 years ago. Today, Mayo Clinic is the largest nonprofit group practice in the world. The second largest is Cleveland Clinic, founded in 1921. The founders of Cleveland Clinic—George Crile Sr., Frank Bunts, William Lower, and John Phillips—were good friends with the Mayo brothers. They hunted and fished together, stayed at one another's homes, and shared ideas on the best way to organize the practice of medicine. These doctors, led by Dr. Crile, were among the first physicians to volunteer when America entered the Great War in 1917. Dr. Crile and his colleagues set up military hospitals not far from the front. They were impressed by the military approach to medicine, which was so different from the private practice model that dominated civilian medicine. Military medicine was collective. Supplies were managed efficiently. Innovations were adopted quickly. Everyone shared the same mission, and all were focused on the patient and making the patient better.
When Dr. Crile and his colleagues returned to Cleveland, they saw an opportunity to create an ideal medical center. They wanted to start with a blank slate and apply the lessons of the Mayo Clinic and military medicine to create a new kind of medical enterprise. Thus was born Cleveland Clinic.
We are a nonprofit group practice. Nobody owns Cleveland Clinic. We are a community trust.
Board of Directors
At the top of the organization is an elected board of directors. The board oversees our nonprofit mission, approves budgets, sets compensation, and manages property transfers. The board includes business leaders, philanthropic leaders, and community-minded individuals.
CEO and President
Next is the CEO, who is also president of the board. The CEO sets policies in collaboration with an executive team and oversees the administration of all clinical and operational activities. The CEO communicates the organization's progress to caregivers, along with its mission, vision, and values.
Chief of Staff
The chief of staff manages all affairs relating to the employment of Cleveland Clinic's medical staff.
Staff Physicians and Scientists
Cleveland Clinic has 3,000 salaried physicians and scientists on staff. These professionals represent 120 medical specialties and subspecialties. All are on one-year contracts and are subject to annual performance reviews.
Support and Services
Cleveland Clinic's medical staff is supported by more than 40,000 caregivers, including 11,000 nurses. These caregivers include allied health professionals, administrators, clerical workers, maintenance personnel, information technology experts, financial experts, billing and appointment-making personnel, and hundreds of other job categories. All contribute to the patient care experience.
Cleveland Clinic is a physician-run organization. This is a big distinction. There are good arguments for the lay administration of some types of medical centers. But more than 90 years of experience has convinced us that physician leadership is best for a nonprofit group practice. Doctors bear the ultimate responsibility for the health and well-being of their patients, so it makes sense that doctors, rather than laypersons, make the decisions about the functional activities that surround patient care. At Cleveland Clinic, a physician CEO and president, a physician board of governors, physician chairs of institutes, and other physician leaders make key decisions for the organization (albeit with the advice and consent of a lay board of directors and in collaboration with nurses, scientists, and lay administrators at every level). The authority granted to doctors may be one of the reasons that Cleveland Clinic physicians score so well on employee engagement surveys: their collective power is commensurate with their responsibilities. The judgment of medical experts ensures that every policy and procedure implemented serves the goal of providing patients with the best care possible.
Arguments for and Against the Group Practice Model
If the group practice model is so effective, why aren't there more group practices? Doctors resist the group practice model for the same reason that the Green Mountain Boys resisted the British: they like their independence. The medical profession attracts smart, capable, self-driven individuals. They can and do enjoy successful careers managing their own affairs in private practice.
Traditionally, hospitals are not expected to lead healthcare. Rather, they serve as a doctors' workshop, where physicians can make decisions about their patients' care without bureaucratic encumbrance. One historian noted that when recognizably modern hospitals first emerged in the late nineteenth and early twentieth centuries, "the physician hierarchy and organization was separate from the administrative hierarchy and organization." This still holds true in many hospitals today.
Patient preference also plays a role. The memory of the country doctor who travels from house call to house call with a black bag is cherished, as is the Norman Rockwell image of the kindly practitioner taking a patient's pulse with a pocket watch.
Given these entrenched views, the founders of early group practices were not popular with the medical establishment of their day. They were called "medical Soviets," "Bolsheviks," and "communistic." Professional associations railed against what they termed the "corporate practice of medicine." When some physicians in Palo Alto, California, attempted to start a group practice, they were barred from their local medical association. The American Medical Association countered the growing menace of the group practice by publishing a reaffirmation of what it believed were the key principles of the medical profession: solo practice, fee-based compensation, individual physician control over the services provided, and "the conviction that medical institutions are but logistical extensions of physician practice." In Northeast Ohio in the 1920s, the local medical powers were so alarmed by the prospect of a group practice in their midst that they threatened the founders of Cleveland Clinic with the loss of admitting privileges at local hospitals. In response, the Cleveland Clinic group built its own hospital, which has since grown to a 1,300-bed complex on its original site.
Good arguments on both sides of the group practice controversy existed then, just as they do now. Many people believe that the group practice model sullies the doctor-patient relationship, making doctors more beholden to the organization than to the patient. Some can't shake the idea that giving doctors salaries leads to inattentive care. The laws and regulations governing medicine also tend to favor the private practice model. Some state legislatures have passed measures prohibiting the corporate practice of medicine. In its early days, Cleveland Clinic had to take complex legal roundabouts simply to collect fees and distribute salaries to doctors.
But the group practice pioneers also had their champions. In 1932, a committee of enlightened medical reformers declared that "[m]any of the difficulties in present medical practice can be overcome, wholly or in part, by group organization."
The recent national debate on healthcare reform, leading to the Patient Protection and Affordable Care Act being signed into law in 2010, thrust the group practice model back into the spotlight. Today, the group practice model has supporters at the highest levels of government. In 2008, for example, President Barack Obama told a national television audience that Cleveland Clinic, Mayo Clinic, and similar practices "offer some of the highest quality of care in the nation, at some of the lowest costs in the nation." Four years later, both President Obama and Governor Mitt Romney mentioned Cleveland Clinic approvingly in their first presidential debate, on October 3, 2012.
Still, resistance among doctors dies hard. It's not easy to cast off the Lone Ranger mentality. Some doctors continue to believe that their individual brilliance will be stifled in a collaborative setting. Others maintain that getting doctors to agree and work together is a hopeless task. Dr. Harry Hartzell, a retired pediatrician from the Palo Alto Medical Foundation, once said, "Three types of people don't get along in a group: the hard-driving entrepreneur who wants to create an empire; someone who always wants to have a minority opinion; and a person who doesn't like to discuss issues, negotiate and compromise."
There are good arguments on both sides. But the success of Cleveland Clinic, Mayo Clinic, the Palo Alto Medical Foundation, and other group practices testifies to the value of this model in delivering exceptional and efficient care.
Measuring Exceptional Care
Excellent outcomes such as Dominic Cantwell's are the rule, not the exception, for large medical groups, as evidenced in part by published outcomes and rankings by reputation or quality. The Centers for Medicare & Medicaid Services publishes a number of quality and safety indicators for hospitals on its website, cms.gov.
Another widely acknowledged and frequently cited measure of overall hospital and specialty quality is the annual U.S. News & World Report "Best Hospitals" rankings. U.S. News factors in a variety of measures, from reputation to mortality rate to nurse-patient ratio, to arrive at its conclusions. The large group practices are disproportionately represented at the very top—Mayo Clinic and Cleveland Clinic are regularly ranked among the top four hospitals in America. Intermountain Healthcare's Intermountain Medical Center is ranked the top hospital in Utah, and its LDS Hospital ranks third. In 2013–14, Cleveland Clinic was ranked number one in America for cardiac care for the 19th year in a row, and number two in urology, nephrology, diabetes and endocrinology, digestive diseases, and rheumatology. Mayo Clinic was number one in five specialties. It seems fair to conclude from these results that large group practices must be doing something right.
Excerpted from The Cleveland Clinic Way by Toby Cosgrove. Copyright © 2014 Toby Cosgrove. Excerpted by permission of McGraw-Hill Education.
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