As chief medical operations officer at the Cleveland Clinic, Marc Harrison, MD, provides clinical oversight to operational decisions for this remarkably successful physician-led organization. U.S. News & World Report lists it among the top four hospitals in the nation and No. 1 for heart & heart surgery. On the cost side, the Dartmouth Atlas of Health Care says the Cleveland Clinic is markedly less expensive than most other prestigious healthcare organizations in treating chronically ill Medicare patients in the last two years of life.
Q: We all know how successful the Cleveland Clinic has been, but can its success be replicated at other institutions?
Marc Harrison: The Dartmouth Atlas shows there is a relationship between our group practice model and lower costs — not just for the Cleveland Clinic but for other group-model organizations as well. Accountable health organizations, which tightly integrate a hospital with physicians and other caregivers, can bridge the gaps between them and erase redundancies.
Q: Is physician leadership key to the clinic's success?
MH: A group model led by strong physician-leader can be very successful (Delos "Toby" Cosgrove, MD, is CEO of Cleveland Clinic). When physicians are asked to do something, it resonates more when it comes from a doctor.
Q: However, some physicians haven't done well in leadership roles, presumably because they lacked the necessary management skills.
MH: I'm sure there are plenty of physician leaders who have done a terrible job running healthcare organizations, but there are many successes, too. I believe it does help to have management training. I have a master's degree in medical management from Carnegie Mellon. In this environment, it is important that the chief medical officer works closely with the CFO. This can be a challenge because historically this is not a "Kumbaya" relationship. But it has been working very well with my non-clinical counterpart (chief of operations William Peacock III).
Q: Can your success with employed physicians be matched at hospitals?
MH: Employing physicians in large groups has many advantages. It allows doctors to do what they do best: clinical care. However, there can be barriers for hospitals that want to completely integrate physicians.
A tremendous sea of change is taking place in healthcare. Until recently, the medical profession was a cottage industry, with small, independent practices. Now a lot of young physicians are clamoring to join the group model. Currently, just 10 percent of physicians under age 40 are in a traditional private practice. That is astounding to me.
Q: How has the recession affected your operation?
MH: In late 2008, we took a very hard look at the budget. We were able to contract but did not lay off anyone. We said we were not going to give out raises, but by the middle of 2009 we were able to rescind that decision. As it turned out, we saw a substantial increase in our operating profit margin for the first six months of the year.
Q: How does the Cleveland Clinic use data?
MH: The Cleveland Clinic has 35-40 different data sets, such as quality, blood banking and laboratory, to name a few. Data are retrievable and reportable on each authorized employee's dashboard, displayed on their computer screens. The dashboard has a common look and feel and the display is close to real-time. The EMR, for example, is updated every 30 seconds. This information is highly drillable. We can show blood utilization for the whole organization and then drill down to the individual department and individual physician.
Three years ago there were 100-150 users of healthcare data at Cleveland Clinic; now there are 3,000 users. One of our super-users is the CEO (Dr. Cosgrove). Using the data system, we can go through our budget line-by-line. We can review revenue and expenses and drill down to the individual service line. When we are in a meeting and have a question about operations, we can run a report and answer it right then and there, instead of waiting a few days for the data to be prepared.
Q: How does the Cleveland Clinic use data to evaluate physicians?
MH: We use clinical data in doctors' annual reviews, quarterly balance scorecard reviews and monthly business reviews. It's extremely important that this data is accurate because we are using it to change physicians' behavior. If I beat someone over the head with the wrong data, I have lost their trust forever.
We show them metrics not only on clinical measures but also on such matters as access and patient satisfaction. We can drill down to the individual doctor. It is a very powerful tool. It has changed behavior of many areas in the organization, in a good way.
When you show them data on patient care, doctors will do almost anything for the patient.
Q: Your physicians are limited to one-year contracts, contingent on passing a performance review. Can you explain how that works?
MH: The review process is the cornerstone of our group-employed model. It is a way to translate the goals of Cleveland Clinic to the front lines. It's an opportunity for renewal and recognition. Everyone goes through it. I go through the same process with my boss, Dr. Cosgrove. I see it as an opportunity to have a formal dialog around the goals of the organization. The metrics we review aren't just financial but also cover quality and what we call "citizenship," a doctor's ability to function within the organization.
Q: In 2006, the Cleveland Clinic replaced clinical departments with a system of 25 institutes, based on a disease or organ systems. Why was that done?
MH: It's an organizing principal that makes more sense. In the traditional healthcare organization, heart surgeons and cardiologists, for example, are in different departments, work for different people, have different business plans and separate profit & loss statements. And yet they have similar kinds of patients and they may even directly compete for some procedures, such as percutaneous heart valves. Combining these functions into one heart institute is easier to manage and easier for patients to understand. Another example of bringing together disparate functions into one unit is our digestive disease institute.
The institute-based system is popping up at in healthcare organizations, including a local competitor, University Hospitals. Imitation is the sincerest form of flattery! It's beautiful to work within the framework of these institutes. Teams of physicians decide what products are chosen. Both employed physicians and private practitioners affiliated with the Cleveland Clinic decide on best practices.
Q: The clinic's department of Strategic Planning and Continuous Improvement seems large, with 50 employees. What sort of work do they do?
MH: The department has shown a tremendous return on investment. Forty of these employees are engineers, working with industrial engineering techniques like "lean," which can improve throughput and remove waste in areas like the ED. The department's goal is to empower clinical staff to take care of patients. When administrators of the clinic's 25 institutes were asked to name their three greatest accomplishments, 20 of the 25 listed performance improvement.
Learn more about the Cleveland Clinic.