Fostering Collaboration in Treatment and Discovery

As President and Chief Executive Officer of Cleveland Clinic (my.clevelandclinic.org) in Cleveland, OH, Delos M. “Toby” Cosgrove, MD, has overseen that institution's transformation, in his words, “from a doctor-centric organization to a patient-problem-centric organization.” Once following the traditional hospital model in which departments of surgery and medicine were separate and medical specialists in one organ system or disease state might never speak to colleagues specializing in another, Cleveland Clinic recently embarked upon a major effort to organize its clinical staff into broad institutes encompassing closely related organ systems and diseases. This approach, Dr. Cosgrove explains, can improve medical care for the individual patient and foster a collaborative environment among clinicians that leads to discovery, innovation, and ultimately, enhanced treatments and better outcomes for patient populations. It was a “novel idea” to “think a hospital should be organized around patients instead of around doctors,” observes Dr. Cosgrove. That idea developed from a sense that the traditional organizational model did not take full advantage of the resources a hospital has at its disposal. As a cardiac surgeon in a department of surgery, Dr. Cosgrove met formally with other types of surgeons—neurosurgeons or colorectal surgeons, for example—with whom, he says, “I had almost nothing in common except that we used operating rooms and wore gloves.” In contrast, he explains, “I had everything in common with the cardiologists: we shared patients, we shared disease problems … gradually the lines between surgery and medicine were blurring.” The unorthodoxy of a hospital in which cardiac surgeons would share departments with cardiologists was not unwelcome to many members of the Cleveland Clinic community who could imagine some of the potential benefits such a restructuring would bring. Dr. Cosgrove notes, “Nobody came and said, ‘This is a crazy idea. This will never work.’” He acknowledges, however, that there was significant concern over the logistical details of the plan, with many of the clinical staff left to wonder, “Who am I going to report to? Where's my office going to be?” Certainly these were legitimate questions: dissolving the traditional medical and surgery departments meant rethinking organizational hierarchies and relocating specialists in related treatment areas so that, for example, the neurosurgeons, neurologists, and psychiatrists could be housed together in their own institute. Despite clear challenges that would have to be handled with care and sensitivity, Cleveland Clinic forged ahead with its plan, seeking the opportunity to provide better patient care and enhance multidisciplinary collaboration. Two years on, after a careful and deliberate implementation of the new organizational model that spanned 18 months, Dr. Cosgrove reports that Cleveland Clinic has settled into its new structure, and he believes the new organizational model has actually made the institution's clinicians more comfortable—and less anxious—than they were before the move. Cleveland Clinic now has 16 clinical institutes, from its Urologic and Kidney Institute to its Cancer Institute, and additional supporting institutes, such as the institutes for anesthesiology and imaging. The tremendous effort required for this transformation is already yielding impressive successes in patient care and medical innovation. As salaried employees, doctors at Cleveland Clinic are immune to the potential personal financial conflicts of interest others encounter when they deliberate about appropriate medical procedures and the financial rewards that may accrue to those who choose one treatment over another. The institution's reorganization along the lines of organ systems and disease states goes one step further, encouraging efficiency and best practice by grouping specialists treating a patient with a particular condition under one roof and thus removing incentives for doctors to recommend procedures that benefit their own department. Dr. Cosgrove illustrates this point with the example of a patient with coronary artery disease. For the cardiac surgeon and the cardiologist, who both now work for the Heart and Vascular Institute, he explains, “it makes no difference to anybody in terms of finances whether the patient gets a stent or a coronary bypass operation.” Relieved of subtle pressures to compete for institutional resources, doctors and surgeons at Cleveland Clinic are well positioned to make recommendations for their patients based on patient need. The housing of related therapy areas in the same institute results in other benefits too. At the Orthopaedic and Rheumatologic Institute, watching a large number of patients come to Cleveland Clinic to be treated for fractures, rheumatologists inquired of their orthopedic colleagues whether some of these patients might have problems with bone metabolism. As a result, doctors treating patients with fractures started looking for evidence of bone metabolism issues, enabling fuller and more complete diagnoses and treatments. Similar questions are being raised across a range of disciplines, Dr. Cosgrove says, prompting a healthy examination of those disciplines and enhancing patient care as a result. Dr. Cosgrove emphasizes that the kind of collaborative spirit he celebrates in the restructured institution was present in Cleveland Clinic prior to the change, but he says that the new physical and organizational environment truly fosters collaboration and a multidisciplinary focus on the patient. In the restructured institution, unintended bureaucratic barriers and departmental boundaries are less likely to get in the way of productive conversations between colleagues, and in some cases the reorganization has prompted specific and concrete efforts to construct spaces where different specialists involved in a patient's care can meet, converse, and work as a team. Dr. Cosgrove points to a specially constructed operating room in the Heart and Vascular Institute that includes a catheterization laboratory where a catheter can be used to implant percutaneous aortic valves in patients. “In that room,” Dr. Cosgrove explains, “there will be a cardiac surgeon, a cardiologist, an echocardiographer, and an anesthesiologist, all working together.” Cleveland Clinic has conducted on the order of 100 iterations of this still experimental procedure—the largest number to be performed in the United States, Dr. Cosgrove says—and done so without a death, an achievement he implicitly ascribes to the strength of the teamwork enabled by the new structure. The benefits of this newly fostered collaboration can, of course, extend far beyond the patient's bedside or the operating room. The Cleveland Clinic restructuring was also motivated by the belief that, as Dr. Cosgrove says, “innovation generally takes place at the borders of disciplines.” He observes, if “you put multiple disciplines together physically and [they are] working on similar problems … you begin to get innovation.” As the head of Cleveland Clinic—an institution that President Obama has praised for its approach to health care delivery and that is considered one of the most cutting-edge health care systems in the world—Dr. Cosgrove has responsibilities that include oversight not just of Cleveland Clinic but also of its extended network of community hospitals, health and surgery centers, and sites in Weston, FL, and Toronto, Canada. There are two further sites in development, Cleveland Clinic Abu Dhabi in the United Arab Emirates and Cleveland Clinic Lou Ruvo Center for Brain Health, created in collaboration with the Lou Ruvo Brain Institute, in Las Vegas, NV. Given the history of Dr. Cosgrove's career, it is no surprise to find him at the helm of Cleveland Clinic at a time of such change and advancement for the institution. After pursuing his undergraduate education at Williams College in Williamstown, MA, he attended the University of Virginia's School of Medicine in Charlottesville, VA. He finished his medical training at Massachusetts General Hospital and Boston Children's Hospital in Boston, MA. A decorated Vietnam veteran—he served as a surgeon in the US Air Force, for which service he received both the Bronze Star and the Republic of Vietnam Commendation Medal—in 1975 he came to Cleveland Clinic, where he has remained ever since, being named the Chairman of the Department of Thoracic and Cardiovascular Surgery in 1989 and Chief Executive Officer and President in 2004. At the start of his long career at Cleveland Clinic, Dr. Cosgrove gained extensive experience quickly, being one of five cardiovascular surgeons at one of the largest medical centers in the United States at a time when, as he notes, “coronary artery disease was being operated on at a very high rate.” With each surgery, Dr. Cosgrove gained further insight into the problems and complications that could result from such surgeries and the possibilities for greater efficiencies and safeguards that could lead to safer, more effective procedures. As an example, in the late 1970s, Dr. Cosgrove and his colleagues began following up with patients on whom they had performed second operations, or “re-dos.” The follow-up conversations revealed that, on the whole, the patients were doing very well with one notable exception: on the order of 15–20% of them had suffered a bad bout of hepatitis following their second surgery. Concerned by this data, the doctors investigated and discovered that these patients were receiving blood transfusions of such considerable volume in the course of their surgeries that their risk of contracting hepatitis through contaminated blood was considerably heightened. As a result, Dr. Cosgrove explains, “we began a whole program of blood conservation, which we wrote about and developed methods for …[we] developed new surgical techniques to reduce the blood and ways that we could salvage the blood and wash it and give it back to the patient.” These efforts, he says, “took our blood utilization down to next to nothing.” Dr. Cosgrove explains that these experiences introduced him to the idea that “by dealing with a problem and incorporating industry and new techniques, you could really begin to make a difference.” Given his training as a cardiothoracic surgeon, he became interested in the development of surgical instruments as well. In one case, Dr. Cosgrove relates, a study of autopsies of patients having undergone cardiac surgery revealed that the “patients had flecks of cholesterol scattered throughout all of the organs in their bodies.” It was determined that the cholesterol crystals came from erosion of atherosclerosis in the patients’ ascending aortas as blood was reintroduced at too great a velocity to the body via a heart and lung machine. Dr. Cosgrove and his colleagues spent 2 years, he says, “developing a way to return the blood to the patient and essentially spray it in as you would water the flowers as opposed to how you would clean the patio.” The resulting low-velocity aortic cannula helped decrease the incidence of stroke in cardiac surgery about 30%. It is just one among the many instruments for which Dr. Cosgrove currently has 30 patents on file. It is this same innovative spirit that Dr. Cosgrove hopes to continue to foster in the newly reorganized Cleveland Clinic. He envisions doctors making observations at the bedside or in the operating room and then “going back and trying to figure out how it worked and developing new products and new methods.” With the new and exciting conversations clinicians can now have with their peers in related therapy areas, Cleveland Clinic is poised to fulfill this vision and continue the tradition of clinicians translating their observations into better, more effective care.

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