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<a href="http://www.nytimes.com/"><img src="http://graphics8.nytimes.com/images/misc/nytlogo153x23.gif" alt="The New York Times" align="left" border="0" hspace="0" vspace="0"></a>
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<div class="">December 24, 2012</div>
<h1>Approaching Illness as a Team</h1>
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<p>
The <a href="http://my.clevelandclinic.org/default.aspx">Cleveland Clinic</a>,
long considered a premier medical system, is gaining new renown for
innovation in improving the quality of care while holding down costs.
</p>
<p>
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. </p>
<p>
<a href="http://my.clevelandclinic.org/neurological_institute/default.aspx">The Neurological Institute</a>,
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.
</p>
<p>
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.
</p>
<p>
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.
</p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
Still, many patients are clearly unhappy. A series this year about confusing medical bills and unexpectedly high charges by <a href="http://www.cleveland.com/healthfit/index.ssf/2012/10/cleveland_clinic_patients_othe.html">The Plain Dealer</a>
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. </p>
<p>
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 <a title="UHC Award" href="https://www.uhc.edu/docs/500111182_Press_Release_RisingStar2012.pdf">in September</a>
for significant improvements over the previous year in quality, patient
safety and clinical effectiveness, an indication that its quality
efforts are taking hold. </p>
<p>
The Cleveland Clinic’s progress in restructuring itself, said <a href="http://www.hbs.edu/faculty/Pages/profile.aspx?facId=6532">Michael Porter</a>,
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.” </p>
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