[Vision2020] Approaching Illness as a Team

[Art Deco]

  [image: The New York Times] <http://www.nytimes.com/>

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December 24, 2012
Approaching Illness as a Team

The Cleveland Clinic <http://my.clevelandclinic.org/default.aspx>, long
considered a premier medical system, is gaining new renown for innovation
in improving the quality of care while holding down costs.

In its most fundamental reform, the clinic in the past five years has
created 18 “institutes” that use multidisciplinary teams to treat diseases
or problems involving a particular organ system, say the heart or the
brain, instead of having patients bounce from one specialist to another on
their own.

The Neurological
Institute<http://my.clevelandclinic.org/neurological_institute/default.aspx>,
for example, provides both inpatient or outpatient care for those with
strokes and brain tumors, as well as those with epilepsy, multiple
sclerosis, depression and sleep disorders, among other conditions.

On a recent visit, we observed one such team, consisting of a neurosurgeon,
a neurologist, a neuroradiologist, a neurologist with advanced training in
intensive care, a physical and rehabilitation doctor, a medical resident, a
physical therapist and a nurse. As they made rounds from patient to
patient, they had a portable computer that displayed electronic medical
records so that the whole team could see how the patient was doing and plan
the course of care for the day.

This team approach can improve the quality of care because all the experts
are involved in deciding the best treatment option, which can save time and
money. The neurological team, by consensus, has been better able to
determine which acute stroke patientsneed a risky and expensive treatment
that involves threading a catheter through an artery in the leg up into the
brain to destroy a clot. It cut the use of that treatment in half, reducing
costs and deaths and improving outcomes.

The Cleveland Clinic has strong leverage to drive such reforms because its
staff physicians are salaried and are granted only one-year contracts and
subjected to annual performance reviews. Those reviews apply measures of
quality, like patient improvement, patient satisfaction and cost
reductions. It raises the pay of those who get high marks, reduces the pay
of poor performers and even terminates some doctors who fall short. This
approach could become more widespread as more hospitals and doctors move
toward the salary-based model.

Data analysis to evaluate how well treatments work is also a big part of
the medical practice. For instance, the clinic analyzed outcomes for heart
surgery patients and found that those who had received blood transfusions
during surgery had higher complication rates afterward and a lower
long-term survival rate. As a result, it has adopted strict guidelines that
limit the use of transfusions.

Such judgments about a treatment’s effectiveness are made by doctors, not
by financial administrators, so they tend to be accepted. One analysis
found that suturing could be done as well with a $5 silk stitch as with a
$400 staple, leading to a big drop in the use of the staples. At the same
time, the clinic has also carried out simpler reforms, like improving
sterile conditions, which has reduced catheter-related bloodstream
infections by more than 40 percent and urinary tract infections by 50
percent. All this has happened in a remarkably short time. Patients seem to
like the treatment they get. A federal government survey of patient opinion
last fall found that 80 percent of the patients gave the Cleveland Clinic a
high rating over all and 84 percent would recommend it to others, well
above the state and national averages in the 69 percent to 71 percent
range.

Still, many patients are clearly unhappy. A series this year about
confusing medical bills and unexpectedly high charges by The Plain
Dealer<http://www.cleveland.com/healthfit/index.ssf/2012/10/cleveland_clinic_patients_othe.html>of
Cleveland elicited hundreds of patients’ complaints mostly directed
against the clinic, because it had reclassified off-campus physician
practices and health centers as hospital outpatient facilities and tacked
on a “facility fee” for services previously billed at lower doctor’s office
rates. The clinic says the added fees are justified because it provides
better quality controls and health information technologies in its
outpatient units than that available in a typical doctor’s office.

Medicare’s spending per patient at the clinic for an episode of illness
that requires hospitalization is below the national median, suggesting that
the clinic’s cost-cutting efforts are working. The University HealthSystem
Consortium, an alliance of the nation’s leading nonprofit academic medical
centers and teaching hospitals, gave the clinic one of its “rising star”
awards in September<https://www.uhc.edu/docs/500111182_Press_Release_RisingStar2012.pdf>for
significant improvements over the previous year in quality, patient
safety and clinical effectiveness, an indication that its quality efforts
are taking hold.

The Cleveland Clinic’s progress in restructuring itself, said Michael
Porter<http://www.hbs.edu/faculty/Pages/profile.aspx?facId=6532>,
a Harvard professor who analyzes health care delivery and organizational
change, is “light speed” compared with other institutions. The clinic is “a
model of where we need to go,” he said, “Not perfect, not done, but far
along.”


-- 
Art Deco (Wayne A. Fox)
art.deco.studios at gmail.com
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