A medical condition should be defined from the patient’s perspective. It should encompass the set of illnesses or injuries that are best addressed with a dedicated and integrated care delivery process.
—Michael E. Porter and Elizabeth O. Teisberg, Redefining Health Care: Creating Value-Based Competition on Results, 2006
Every academic health center stands on the so-called “three-legged stool” of patient care, research, and education. The dimensions of these legs may differ by institution, but the one representing patient care is critical to support the entire enterprise platform. A traditional specialty-oriented, siloed, economic-driven, paternalistic, caregiver-focused system not placing patients first will, we predict, no longer be accepted. Even if excellence in research and education is evident, organizational approaches to patient care must change. Kastor1,2 has addressed in a thoughtful Point–Counterpoint our Cleveland Clinic approach to this challenge, and here we offer our own perspective on the institute-based model of institutional organization.
Institutes at the Cleveland Clinic
Ours was an organizational change designed to promote patient-centric activities without neglecting education and research mandates.3 We designed and implemented the transformation from a traditional departmental model to a system of institutes with our culture and history in perspective. This system is an innovative and nontraditional approach to the clinical and business structure of an academic health center because of the implementation scheme, which was applied to every clinical and support program at the Cleveland Clinic, and the sometimes-unusual combinations of specialties and services, which had previously operated with little collaboration. On the basis of our experience, we believe an institute-based structure is the optimal organizational approach for academic health centers to better achieve their tripartite mission.
The concept of academic specialty-based practice and patient care evolved in the mid-20th century when a scheme for financing the medical profession emerged that shifted educational and organizational models to ones that encouraged specialization. Academic health centers more enthusiastically embraced the concept of specialty care, which began formally in North America with the formation of the American College of Surgery a few decades earlier. This spurred creation of independent departments largely split between “medical” and “surgical” interests and efforts. The Veteran’s Administration graduate medical training programs, National Institutes of Health funding of new postdoctoral programs, and external research funding made available to medical schools for development of specific clinical areas are examples of this ideological division.4 As medical specialties evolved, self-contained units of practitioners matured and characterized academic health centers organized around independent departments.
One of the goals of Cleveland Clinic’s founders was to create an academic group practice that embraced medical specialization and subspecialization along with the significant advantages and expertise that they bring to patient care. Education and research were also priorities. An early Cleveland Clinic chart published in 1938 characterized our operation along the lines of most academic health centers of the era with a split between research departments, educational activities, and clinical divisions, where specialties such as medicine, surgery, ophthalmology, neurosurgery, urology, orthopedic surgery, and pathology, to name a few, were further compartmentalized to become separate entities.3
Creating the right kind of institutes
When designing our new operational paradigm, the term “institute” seemed appropriate to characterize the desired structure because it generally refers to an amalgamation of traditionally separate medical specialties into united but distinct units, particularly units with a research or educational mission. However, whereas some academic institutes have previously been conceived to improve patient care, education, and research, others seemed more concerned with securing space, power, and resources. Amalgamated profitable specialties can become cash-generating silos that narrow the institution’s research and educational efforts while serving some specialty groups more than others. This imbalance can be detrimental to meeting the global mission of the institution.
When we began to integrate traditionally separate departments, particularly when pulling together select medical and surgical specialties, our main desire was to improve patient care. We measure our capacity to do so by our improved ability to provide clinical services, as assessed by patient outcomes and satisfaction as well as administrative and business metrics. Another purpose for the restructuring was to facilitate a more integrated research and education program by enabling teamwork managed by one central figure.
Improving the Patient Experience
Patient care today is complex and requires a cadre of individuals bringing broad knowledge to the clinic. Patient care is often parsed and diced with little coordination, particularly when care is multifaceted. To address this issue, we have organized what we believe are rational combinations of specialties into institutes. For example, in our Neurological Institute, neurology, neurosurgery, psychology, and psychiatry provide integrated and broad-based epilepsy management services. In our Heart and Vascular Institute, cardiac surgery and interventional cardiology are responsible for a tightly integrated service that does percutaneous and minimally invasive aortic valve replacement. In our Endocrinology and Metabolism Institute, our bariatric surgeons, endocrinologists, medical bariatricians, and psychologists focus on a surgical “cure” for diabetes. By rationally integrating services, patients benefit by having a multispecialty team that can coordinate their care and facilitate passage through difficult health care interactions.
Ideally, the teams that make up an institute are physically colocated in the Cleveland Clinic model. Patients enter the system with a complaint or organ-specific problem at a designated portal and can then be cared for with consensus-driven protocols developed by the surgical and medical teams in an institute. Teams focus on specific problems, such as stroke, epilepsy, diabetes, myocardial infarction, or valvular heart disease. At the Cleveland Clinic, the Neurological Institute has executed this organizational philosophy to the fullest, deemphasizing traditional specialty-oriented departments and instead creating “centers” around specific problems.
As a further benefit to patients, this type of organizational structure can help reduce destructive competition among physicians. The institute model facilitates better decision making about how patients are best treated and by whom. In our case, for example, five different specialties (interventional cardiology, neurology, interventional radiology, neurosurgery, and vascular surgery) were clamoring to perform stent implantations for carotid obstruction and competing with one another before we adopted the institute model. Amalgamation of some of these departments into more singular institutes helped address the problems.
The vision of a truly integrated and interactive multispecialty team to care for patients will, we believe, change the traditional structure of health care provision, which has been largely based on the commoditization of medicine. This is the best way, we believe, to reorganize the delivery of care in the academic health center setting. Indeed, reorganization of the health care system more generally has received much recent attention.5–7
Benefits for the Bottom Line
Of course, the economic future of our profession was also a priority during the redesign of our clinical services. We felt strongly that an integrated model would provide better service to patients, be associated with improved outcomes, produce greater patient satisfaction, and create economic advantage by pooling resources when the care of multiple specialties is required.
Providing epilepsy surgery services is an example where neurology, psychiatry, psychology, and neurosurgery are all necessary. We found that, in the traditional departmental model, it was difficult to garner financial resources, support staff, and space from one department to promote another department’s activities, even when coordination of multiple specialties was required for patient care. Furthermore, the question of responsibility for service-line outcomes and operational metrics was blurred in the traditional system. It was unlikely that the Department of Neurosurgery would hire the psychologists necessary for an epilepsy surgery program, even though the Department of Psychiatry and Psychology, because of an economic model where mental health services are not well reimbursed, did not have adequate resources to do so. By the very nature of a siloed organizational structure, transferring resources from one department to another to further service activities does not often happen easily. The institute model has eliminated a considerable amount of this competition for resources among specialties.
Some may argue that we have simply created different and larger silos. Despite that possibility, the Cleveland Clinic institutes primarily charged with clinical care have provided many examples of better meeting our mission. Anecdotes demonstrate improved research interactions. Professional staff bring insight into projects that they would not have participated in before. The same observation can be made with respect to educational efforts.
Achieving Evolution Through Innovation
Evolution means change and is a constant in nature which we must recognize and embrace. In addition to the evolution of health care diagnosis and therapeutics, change in the economics and cultural anthropology of medicine demand innovative strategies to manage that change. We believe that continued irrational grasping at the status quo will prove a disservice to academic health centers’ purpose, well-being, and patients. The importance of embracing change, not for its own sake but as a way to adapt to the environment, cannot be overemphasized. Heraclitus of Ephesus, a pre-Socratic Greek philosopher, held the opinion that “no man ever steps in the same river twice.” He has been credited with the observation that “all things are in flux” and that change is an ever-present characteristic of nature. Perhaps this is why he has been characterized as “the weeping philosopher,” wringing his hands over the world’s evolution.8
We believe that Kastor’s presentation and analysis will stimulate a fair and constructive debate regarding the relevance of the Cleveland Clinic institute approach to academic health center organization. In the end, we must all evolve for the sake of our patients and profession. A new epoch of medicine is at hand where patients are first, and we must reorient our practices to that reality as well as to the emerging “new generation” of professionals.9 As Bob Dylan10 originally sang in 1964, “you’d better start swimming or you’ll sink like a stone … for the times they are a-changin’!”
Acknowledgments: The administrative and professional staff of the Cleveland Clinic made the described organizational restructuring possible and successful, and should be recognized for that fact.
Funding/Support: Drs. Young and Cosgrove are employees of the Cleveland Clinic.
Other disclosures: None.
Ethical approval: Not applicable.