PEPconnect

Delivering high value care: A few insights from Toby Cosgrove

Toby Cosgrove, MD, discusses the question of what quality in healthcare means and provides insights into the transformation of the Cleveland Clinic to become a modern, patient-centric health institution. But what else does the future of healthcare hold?

To be welcome, thank you, nice to be here, thank you. So I'd like to start with you as a leader. You are often described as a gritty leader you have with a lot of perseverance determination. Where does this grid the stamina come from? Well, I think some people may know that. It turns out that I am dyslexic and I didn't know it and never heard the word until I was 34. I just thought that I was slightly slow and so I had to work two or three times as much on most things. Scholastic Lee is, other people did and I think that probably. Fueled my persistence 2004. It was your first year as a CEO and there was a defining moment. Harvard had written a case on the Cleveland Clinic. I think it was Michael Porter. You're in class and a student asked you a question that really changed your belief systems and let to transforming culture at the Cleveland Connect. So tell us more. Yeah, so we started it. Started back a little bit for that and that's how I got the new Michael Porter. I was had about six months, but I was going to be there before I became CEO and so I thought about you know what we are is an organization. Why we're here, why I had a job, why everybody else in the organization at a job. And I came down to the fact that it was we only had a job because we had patients and so that led me to make the announcement on my first speech that it was going to be our motto is going to be patients 1st and that's why we were here. And so we started down that course, and I thought about it was really brought home to me by the instance you referred to at the Harvard Business School, Michael Porter wrote a case study on the Cleveland Clinic, and I went up to Harvard Business School. Never having been in a Business School before, and I was very nervous and I'm up in front of this class. And they're all asking me questions that a girl on the left hand side in the 2nd row raise their hand and said Doctor Cosgrove, he said. My father had Michael valve prolapse and we know that you've done more of those operations than anybody else in the United States, but Doc 'cause we decided not to come to you 'cause we heard you don't have empathy. Doctor Cosgrove, do you teach empathy? Well? Geez, I can't remember anything I said after that. And so then 10 days later I am in Jetta and we're there. We're partners with group that is opening a new hospital there in the CEO stands up and said. This hospital is dedicated to the body and the spirit and the soul of the patient. I'm going, yeah, yeah, yeah, I look over there and there's the King of Saudi Arabian, the Crown Prince, and they're both weeping. So I said, Oh my God, Toby, you missed something. So I think back about my experience in health care and I realized when I was a medical student at the Boston Children's Hospital in one day, we lost five kids in cardiac surgery. And you can imagine what it was like coming back the next day and try to do it again. At mass general, when I was a resident the mortality rate approach, double digits and now and so all of my experience and all of my efforts were directed at trying to make cardiac surgery safer, new operations and new devices, new approaches, and now the mortality rate. And so I spent all my time in the operating room and my concentration in my thinking and now patients. Survived and they expected not to not to do anything else but to survive, and they wanted a relationship with you. And so I'm thinking I've become a technician. I'm not become a physician. And so I had to go back and say, OK, Now we've got to do something different. And So what we did is we took the entire group. Off and well. First of all, we start to think about what's quality in healthcare. Inequality in Healthcare is really three things. It's the clinical aspect and we'd been on that clinical Rd for a long time. We worked on our complications. We were very transparent about our results. In fact, we put out outcomes books every year and believe in transparency for two reasons. One, if you look at your result, you always find something that you could do better, and two were Community resource and we need to be responsive to the Community. About what we are and what we do. So we handle the clinical aspect, but it's also the physical experience an the emotional experience. So the physical experience we worked on. I mean, we did silly things like everybody here put on one of those damn hospital gowns which your cheeks flap in the back as you walk down. The It's the most humiliating thing. So we got Diane Von Furstenberg to redesign the gown for us which is now wrapped ground that covers most of your body. We looked at the architecture. We redesigned the rooms, we thought about it how we wanted to have the hospital perceived as a cyantific clinical place, not like being in your living room. And then we had to deal with the emotional aspect of it. And so we did. We took everybody offline for half a day. 40,000 of our caregivers, and we sat around the table, mixed all up, you know doctors, nurses, janitors, bus drivers, etc. And we talked about the Cleveland Clinic experience. And out of that everybody came out of that, and they got A tag that said caregiver Ann. We now talk, not everybody in the organization is a doctor or a employee. Everybody is a caregiver and that change the organization that improve the patient experience and it really set us on a course to be much more patient centric. And you were one of the precursors. So this was how many years ago? As a decade ago, a decade ago, and if you haven't seen it, there is a fantastic video online that the Cleveland Clinic has put has put together around empathy. It's very emotional, an has absolutely no words in it, so it really, really gets to the to the the core of this empathy. So you've done a lot of patient on patient experience. So what inspired your leadership on the transformation of care delivery you talked about? Outcome measurements So what inspired your vision there? Because you've done a lot. Well. We've you know one of the things that we realized along the way was, you know everything comes out of a patient experience. So we had a couple things we did. The first thing is we had a patient call up urology Department said I'd like to make an appointment and so they gave an appointment in two weeks. Turns out the guy was in acute urinary retention. And couldn't pee. And So what we said was we've got to ask people when they need to be seen. So we started a program of same day appointments. We ask everybody and they call it for appointment. Do you need to be seen today? And they may not be seen by exactly the doctor they want, but will get him seen. We now see 1.3 million same day appointments. The second thing that happened was an experience which was again a little humiliating to me. I think those are probably the things that you remember the best. Is eye operated on a Italian from Buffalo happened to be a relative of my wife's little old lady and did a bunch of coronary bypasses on her. She did great an about the fifth or six postoperative day. I'm summons to the room and I walk in here and here's an angry Italian family. Not a good scene. An I say, Gee, I'm so pleased everything went well. What's the problem? And they say look under the bed. So I get down on my hands and knees and I look under the bed an here under the bed is an empty Ivy bag and dust bunnies. And so the patient's whole experience was ruined by that. And if we look at it in cardiac surgery, 110 people touch a patient. An that whoever either through the bag under or didn't clean up ruined the the efforts of the cardiologist, the cardiac surgeons, the scrub nurses, the anesthesiologist, the intensive care nurses, the Secretary's award floor nurses, the people who brought the food, and so we realized at that time that it was a team event. And so, by the way, it's interesting. We've now taken this. After making everybody a caregiver, we've now taken that in, moved it into the education aspect because we think that we see right now in healthcare education takes place. Doctors over here, dentists over here, nurses over here, physician's assistants over there, and the and so there's no sense of team play. So what we've done is we are putting together a new facility that will have medical school, dental school, PA School, Nursing school altogether, and so they're going to learn together. And as and when they come in the first day, they are going to get a patient and they'll have a student, medical student, nursing student, dental student, PA student, social worker who will follow them and learn how to work as a team because I fully believe that the information in the technology is so great now that it takes a team to do it. And we gotta start educating in a different way. So Speaking of teams, you restructured the organization around. Integrated practice, Eunice, can you tell us a little bit more about this? Yeah, so again, this kind of goes back to my experience, so I'm a cardiac surgeon and we share a waiting room with a cardiologist and I was going back and forth across that waiting room all the time. I'd go to the Cath lab. They come the operating room and it turns out that I'm in the Department of Surgery with colorectal surgeons and the neurosurgeons and the gynecologist that I've got nothing in common with, except we wear gloves most of the time. And they're in the Medicine Department of Medicine. And but we share all the same diseases, the same patients everything. So what we did was we said, OK, rather than having us organized around the guilt system of doctors, why don't we organize around patients problems? So we moved everybody to what we call institutes and we have the heart and Vascular Institute now has cardiologist, cardiac surgeons, vascular surgeon, vascular medicine. The Neurologic Institute has neurosurgeons, neurologists, psychiatrists, urologist are there within the FRA logistics cetera. So we've now moved the the hospital from Doctor Centric to patients. Enter patient, which when I did it. The doctors nobody said that's a bad idea and they all want to know who they're going to report to, and you know where's my office going to be and happily, nobody said that is not work. We gotta go back, yes. So it's been a pretty successful so far, and reordering us around patients problems. So you measure outcomes. Did you measure the outcomes before that change? An after the change an you publish them? I mean, there published the books of outcomes. We have. 29 of them are published on the Cleveland Clinic website. So you could go check over how many years till we can you check when we started in cardiac surgery 20 some years ago and then it just move it. Then it just moved. When I became CEO I said OK now everybody's gotta do it and it was done about the same time as the move to Institute. So unfortunately we can't measure the before and after but we've seen the progress over decade over decade. Yeah so. Different questions I heard you don't hire smokers and I think the first year you became a CEO you picked up a big fight with McDonald's on campus. So what was all of this about? I wanted to be the Big Mac attacker. So what what I if you look at health care really our biggest asset is our people. And I thought I said, you know, we're going to look after you and make sure that we're going to model what good health should be. And the first thing I did is I went after smoking because I thought that smoking as a cardiac surgeon. You just see the ravages of smoking all the time and my father died of emphysema. And So what we did is we started out by saying, OK, we're going to ban smoking any on any of our properties and then we made the bold move and said we're not going to hire smokers anymore now. Funny part about it is the place that has the highest incidence of smoking. Is in the respiratory therapist. Just saying an I thought that you know are we going to be able to find respiratory therapists that don't smoke? Well it happily we have some of the ones who didn't smoke or happy to come work for us, but. And then we said, well, we gotta change the food. So we made about 40 different moves in the cafeteria. We wheeled out the Friars. I asked McDonald's to leave, and unfortunately, I wasn't smart enough to find out that they had a long term contract and then didn't talk with the lawyers ahead of time. So it took me 10 years to get him out of there. But you did. If I did. Yes, yeah persistence. Yes for grit. So all of these changes. Do not imagine that they were all popular with with employees right? An positions in particular. So how did you get physicians to go after your vision? Well, I think you know. When I started, I think most people saw that it's going to be the flavor of the day. Then you just ignore him and it'll go away. But I think the the two things that I think physicians respond to. Since we're all salaried, it didn't make a lot of difference because they were going to get major change in their salary. But what they do respond to is data. And so we collected tons of data. And then we became transparent about it, and we in fact will send we post data on patient satisfaction, for example by name and rank, order by doctors. We post mortality rates by doctors. So we are very data driven and what there's sort of the responses classic. The first response is I don't believe that of my patients are sicker and everybody else is. After you get over that, which takes six months, then it takes another six months before the data starts to get better. And it's just. It's happens every time. That way it's universal. The second thing the doctors respond to is peer pressure. They really do not want to. I mean, nobody wants to graduate last in their class. And so the by the posting of the data they respond. And I think those are by far the two most powerful things that I've seen infers as far as changing doctors behavior is concern. The other thing that's very interesting about the Cleveland Clinic. Everyone has a one year contract, yeah? So how? How do you manage this and how do you get the best doctors to come and work with you is if every year they could get end up without a job. Yeah, so this is a tradition in the organization is different from I think any other one that I'm aware of. First of all, we're physician LED. We're a group practice essentially that makes its rules and selects its leaders an makes the decisions about what hospitals were going to own and what were not. So were tightly integrated. Secondly, we all our employees with a salary with no bonuses and 3rd. We have one year contracts and probably the last thing is that we have annual professional reviews that we take very seriously. We spend 10s of thousands of hours looking at having physician reviews and we get as much much numerical data into that as possible. We've done one other thing recently that. Along those lines we went, we took a page from Jack Welch's book and did force ranking a doctors. So you ask any Department head who's is best and who's this were still tell you, but he would never dare put it down on paper. So we've asked him to put it down on paper. So we celebrate the top 10% and we manage the bottom 10%. But we think people ought to know and where they stand, we certainly didn't medical school and we did in college and there's I think that has been. Very successful, the other sort of thing that we've instigated a few years ago is succession planning. And I think, just incidentally, I think we've not been very good as physicians in developing leadership. If you look at it, we were all selected because we did well in organic, didn't do well. We got through organic chemistry. And then we want to medical school and spent four years memorizing. Then we were interns and we did. He put the chief resident, told us to do, then we became chief residents and did what the junior staff told us to do and he was being told what the chief of Staff told him to do it. By the time you get to be 45, you haven't had an independent thought in your life. You've been. You've been trained particularly around technology and not leadership. And so I think we really have a big opportunity to train. Leaders because just because you've got a great CV and you've published 200 papers on something doesn't mean you're a great leader. And basically leadership is about communication, an communicating an idea and leading people and having emotional intelligence, and that is not demonstrated in most resumes. So you've done great things on patient experience, and you've clearly transformed the Cleveland Clinic in terms of the care delivery. Maybe one last point, unclear delivery. We were discussing at lunch. This is the decentralization of tasks, right? So you have really thought through what should be in the central campus and what should go into the Community Center. So talk to us a little bit about this. Yeah, so we were as a health care system with about 11 hospitals in Northeast Ohio. One of the things that early on that we did we said look. No hospital has to be all things for all people, and there are very highly technical, very expensive things to do that and rarely done like putting pacemakers in people's brains. For Parkinson's, you don't want every hospital doing that, and because you know the more you do something that you better get at it, and the better the quality is in, the cheaper it is, etc. So what we did is, we said, let's take the things that belong in the community, hospitals and moving the community hospitals. So we took obstetrics and we took a lot of pediatric so WellCare out we took. Rehab we took psychiatry and we moved him to the community hospitals and then we had, I think, 5 Community hospitals doing obstetrics and we consolidated them into 3. And so that they main facility now has the highest acuity patients in the United States and the we wind up moving things out to the Community hospitals which really belong in a Community Hospital, not in a high tech facility like the Cleveland Clinic is an I think that winds up getting better care cheaper, and we're increasingly moving things out. We recently moved all our thyroid surgery. Out it doesn't have to be there. All are hernia surgery out of the main campus, which is an expensive place to run and it's it's better care the physicians enjoy it more and we get it out of that main campus. Yes, so. So we have a system now that has a central hospital which is very high tech. Community, hospitals, outpatient facilities and obviously a big push in virtual visits. Let's shift gears for a moment and talk about the Cleveland Clinic as a business. So you took the clinic overseas? What was the what was your thought about this strategy? A little bit happened to, you know, certain dip Italy. So we had operated on the King of Saudi Arabia along time ago as hard on a couple of occasions. And so we had a lot of people coming from the Middle East. And at 9:11 it just stopped. And so my predecessor let said when we go there all going to England. Now why don't we go to London and Medium? So we tried to buy a hospital. We tried to Lisa hospital. We looked at Greenfields and then word got out that we were interested in doing something internationally. And what happened was that the people from Abu Dhabi approaches and said we'd like to have you recreate the Cleveland Clinic here. In other words, a cultural transfer there. So you know that fit the five criteria and that we had. The with the criteria was that we had to have a stable country, stable leadership. We needed to have a long term relationship. No investment from the Cleveland Clinic, and a financial return to the Cleveland Clinic and that fit all of those categories and interesting Lee. Now we have now a major facility in Abu Dhabi. It's the nicest hospital I've ever been in any place. It's 22 stories high, magnificent and the question I always get is well where did the doctors come from? And we had turns out that we had 12,000 doctors apply for privileges. We hired 350 of 'em. 80% are from the United States, 20% from Europe an about a third of those doctors are from the Cleveland Clinic, so we have moved our culture. There is lock, stock and barrel. Could you have done that without the very strong brand of the clinic? Well, I don't think we could have done it without the opportunity, and I think probably the brand of the institution helped in recruiting physicians. And if you look at it, look at doctors in the United States, either they are or their parents are immigrants to the United States and so that a lot of people were interested in having an overseas opportunity because of that relationship. Besides Abu Dhabi, you have Toronto, we have a small facility in Toronto. Which is an outpatient facility and we are entering into new venture in London because we think that this is an opportunity for us to both meet some demands and also introduce and collaborate with what's going on currently in London. You're a firm believer in industry in the fact that the health care industry needs to consolidate to deliver high value care. Why is that? Well, you know. We think it's interesting that we now we have too many beds in the United States right now. And for example, there are about 5000 beds. 5000 hospitals in the United States turns out there. 200 hospital, 201 hospitals in the state of Ohio alone. And think about how healthcare was built. It was built basically after World War Two and a time when there was not a lot of things you could do for people in the hospital and there was not great transportation. Now we've got great transportation and a lot of very sophisticated things we can do, and facilities, and so we have. We are under enormous financial pressure and we have to get the efficiencies and the quality that comes from bigger organization. And so I think that. We're seeing a lot of consolidation against around all branches of health care in the United States now, and I think it's going to continue. A few months ago you moved to Google. I didn't move and you didn't know if you became an advisor to Google. I did. So why did you make this choice? I think that right now let me give you just a few pieces of data. The the amount of data that is being developed right now in Healthcare is amazing. By 2020, the total amount of knowledge in Healthcare is going to double every 73 days. There are there's 5600 journals being published, putting out 800,000 articles a year. There are more is more information in one mammogram than there is in New York City phone book. There are three billion base pairs in every human genome. Huge amounts of data. And I think that that data represents both a problem and an opportunity for us, and I think the problem is that you know, we just can't store it all an in a reasonable sort of away cost effectively. And so I think that's ultimately going to drive people to the crowd to the cloud. Now this interesting part of that is recently three weeks ago at the White House, IBM and Microsoft and Google and all the Facebook and all the players came together and they said, OK, we agree that we will share data in the cloud. We haven't been able to get that from Cerner, an epic. Both you know if the data gradually migrates to the cloud, then there's an opportunity to do that. The other opportunity that I see is cyber security. I think it's going to be more secure there and finally with vast amounts of data, I think we're going to discover things that we had no idea existed before, and so I look at it as an opportunity. I hope that. Google has 35,000 engineers working for them and I suspect that those and they've got vast resources and if we can divert some of that capability to healthcare, I think it'll be a big opportunity for healthcare everywhere. So what are you advising Google to do? You can you can you know pass on this question? Yeah no. I think Google is it right now is. It's a point where they have at least six or seven branches of Google Literall in healthcare in some some way. I think that they need to have some sort of collaboration and coordination on their push and health care, and they are currently trying to work on their strategy and I think they need to help us in healthcare deal with the issues that are making us crazy. I mean, think about making appointment on one end to think about billing at the other. Think about storing all that data. Just let's go back to billing for a second. We have 2000 people at the Cleveland Clinic who work and revenue cycle. And I mean, there's an opportunity to drive the efficiency. If we could develop something that would read the chart. Code it, sign the and pair. Make them send the bill out that I had well done. Now I think about 6 seconds and think about the efficiency that that wouldn't think about. We have 5,000,000 phone calls at our call Center for appointments that doesn't. That's just part of it. So if we 500 people out there just answering the phone, think about you, know the ways that. Managing these sorts of vast boluses of data could really be useful for us, and you know, we saw incredible things that AI is going to bring to us. I know that. We've already seen deep Mind in London developed retinal scan that will make 60 different diagnosis from a retinal scan autonomously. That's that's pretty exciting stuff, so the potential there is there, but it's gotta be coordinated and it should be directed, not at trying to cure cancer, but trying to help us deliver more efficient health care delivery. So clearly the to be Cosgrove book is not over and never writing a book again, promise. No, what but I would be very interested to to read about your next chapter to be. Thank you very much for your time. Thank you very much. Thank you.

SIEMENS .. SIEMENS delivery Healthineers • We enable healthcare providers to increase value by high value care: care SIEMENS A few insights from Toby Cosgrove Improving siemens.com/healthcare-insights Expanding Transforming Digitalizing Healthineers • patient precision care healthcare Delivering high value care experience medicine delivery Dr. Ghada Trotabas Dr. Toby Cosgrove Former CEO and President SVP Marketing, Sales Operations an Custo er Engagement Siemens Healthineers Cleveland Clinic, USA

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