Congress Needs to Improve Quality of Healthcare

Nancy Shute

The ongoing health-care debate in Congress (c) Jennifer Kohnke

Toby Cosgrove, CEO of the Cleveland Clinic, reached out to mentors at the Harvard Business School and elsewhere to learn leadership skills. But he says his real leadership training has come through making mistakes -- and when you're an innovative heart surgeon, those mistakes could be life-threatening for patients. Nancy Shute talked with Cosgrove about how those hard lessons shaped the skills he now uses to lead a $4.6 billion healthcare system with 29,000 employees, as well as to invent lifesaving medical devices.

Excerpts:

We're in the midst of a historic national debate on improving the delivery of healthcare. As a pioneering surgeon and CEO of a major medical center, you're on the front lines. What leadership do we need to fix healthcare?

We've made recent improvement in access to healthcare and some improvement in the ability to drive quality. What we really haven't done is focus on how we get a more efficient delivery system. We really need to coordinate the interaction between hospitals and hospitals, and hospitals and doctors. No longer can we expect all hospitals to be all things to all people all the time; healthcare has become much too complicated for that. We now have trauma centers; we have high-tech cardiac surgery; we have very high-tech neurosurgical procedures. We need to get people to the centers that do things very well, so we have efficiency and quality of care. That requires we have the mass of patients at those centers, because it's called the practice of medicine -- the more you practice at it, the better you get at it, the more efficient you are, and the better the quality of care for the patient.

You run one of the largest hospitals and healthcare systems in the country. What responsibility do hospital administrators have in reforming healthcare?

Hospitals have to understand that they need to come together in systems so they can deliver the level of care that patients need. It's great to have children delivered at community hospitals, but you can't expect a 150- or 200-bed hospital to do great neurosurgery or cardiac surgery or trauma care. People will have access to that through the ability to move patients to other institutions -- just straightforward transportation. And just as important is the ability to move their information around with electronic medical records.

You say doctors have to change how they practice in order to make medicine safer and more efficient. How so?

Doctors have to understand that they are part of a team. Doctors traditionally have been solo practitioners, but as the knowledge base has gotten so much bigger, it's impossible for one doctor to be able to surround all the information that is necessary to take care of patients. Teamwork has got to become an integral part of patient care. The coordination that comes with that will ultimately result in superior care for patients -- better care and more economic care.

Patients feel left out when we're talking about health reform. What can patients do to make their care safer and better?

Patients have a major part to play in their healthcare, starting with keeping themselves well. A great deal of their health and welfare and longevity is going to be related to how they take care of themselves. Patients also need to learn how to find the right care for themselves in the right location, not just expect to go into the emergency room and enter into the system and be taken care of. The more they know about healthcare, the more they pay attention to where quality is delivered, the better the healthcare outcome.

What should our political leaders in Washington do to improve healthcare through health reform?

Congress has done a great job in improving access to healthcare, but they've done only an average job of potentially improving quality of care. They have given economic stimulus funds to promote use of electronic medical records, and they've put together some demonstration projects on healthcare delivery, but they really have not done much to decrease the overall healthcare bill for the United States. That is going to require making the healthcare delivery system more efficient and also putting increasing emphasis on wellness and keeping people healthy. Clearly, if you don't get sick, it's a lot easier and less expensive to take care of you.

What innovations have you implemented at the Cleveland Clinic that could be adopted in other healthcare systems?

One of the things that works in our favor at Cleveland Clinic is that we are all salaried employees -- we have no financial incentives in terms of delivering more care or less care. Second, we have quality control around our physicians. They all have one-year contracts and annual professional review. That's probably our best quality control.

Another thing is that we have reorganized ourselves around patients and patients' problems. Traditionally, you have a department of surgery, but the only thing [the doctors have] in common is that we all wear gloves. Now we have a heart and vascular institute that has cardiologists, cardiovascular surgeons, and vascular surgeons all in the same location. If you have a headache, you may not know if you need a psychiatrist, a neurologist, or a neurosurgeon, but they're all there. That gives the patient the advantage of a multidisciplinary approach to their problem. It also allows the [care providers] to come together and think about innovative approaches. As the borders between surgery and medicine begin to become less clear, it's obviously an advantage to have both specialties in the same organization, so they can work together.

Our country faces great challenges in the next decade. How can we develop leaders equipped to meet those challenges? And how do you meet those challenges?

Doctors traditionally have not had schools for leadership, but leadership is not something that is inherent; you learn it and you work with it. It's important that you get opportunities early on to lead and develop those capabilities, and get coaching. I was very fortunate. Early on in the military, I was given command of a 100-bed hospital in Vietnam, which gave me my first real taste of leadership. I had other opportunities as I progressed up the ladder in the Cleveland Clinic, particularly as chairman of the department of thoracic and cardiovascular surgery, which was a very large organization with big responsibilities. I actively tried to learn leadership; it was work both scholarly and practical.

Did you have mentors in developing your leadership skills?

I did. I had multiple mentors. I looked a lot outside the business of medicine. I got some great mentoring by Michael Porter at the Harvard Business School, and I sought out people in other industries as well.

Do you learn from your mistakes?

I have been very good at making mistakes. Just by my background -- I am dyslexic, so I've had lots of scholastic failures along the way. Over time, I learned that failure was not such a bad thing. Failure was only bad if you didn't recover from it. I am perfectly willing to try new things, make a mistake, try to learn from it and then push on. To be afraid of failure is a self-limiting event. I have about 30 patents, and most of those came from mistakes I have made and things that didn't work until I got it right.

For instance, patients were having strokes during cardiac surgery. We found that the way we returned the blood to the patient brought the blood back in in a very jetlike fashion, which knocked little atherosclerotic plaques off. That disaster for the patients led to going back to see how we could do it better. We developed a catheter that sprayed the blood back into patients rather that jetting it back in. That reduced the incidence of stroke by about 30 percent.

So, lots and lots and lots of mistakes.

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