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Point–Counterpoint: The Cleveland Clinic Institute System Is the Right Structure for Academic Health Centers in the 21st Century

Kastor, John A. MD

doi: 10.1097/ACM.0b013e31824d5947

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Dr. Kastor is professor of medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; e-mail:

Editor’s Note: This essay presents arguments for the purpose of revealing key issues about a topic, and does not necessarily represent the views of the author. Commentaries by M. Karpf and R. Lofgren, and J. Young and D. Cosgrove, appear on pages 555-556 and 552-554.

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Cleveland Clinic leaders believe that their institute-based administrative system, implemented in 2008, provides better care for patients and potentially more effective control of costs than the traditional department- and division-based academic health center (AHC) structure. In this essay, I briefly describe the institute system and then discuss its advantages over the traditional AHC structure.

The Cleveland Clinic system replaces the traditional structure with institutes of doctors and staff organized by diseases and organ systems rather than by specialties or professional and academic groups. Seven institutes combine medical and surgical groups. Thirteen include more than one medical or surgical field without incorporating disciplines from both. Six institutes have primarily administrative functions (Supplemental Digital Tables 1–3, Each institute has a chair who is a member of, but not the director of, one of the departments in the institute. The chairs are chosen, according to the Cleveland Clinic CEO, primarily on the basis of their leadership abilities and not “on their being famous or on the length of their CVs.”1

Among its most important features, the institute system facilitates relationships among physicians based on diseases rather than departments. This arrangement recognizes that, in providing clinical care, doctors often work more closely with colleagues in different departments than with colleagues in their own departments. For example, the Heart and Vascular Institute brings together clinicians practicing cardiology and vascular medicine with those specializing in cardiothoracic surgery and vascular surgery. The Digestive Disease Institute contains the medical specialties of gastroenterology and hepatology, and the surgical specialties of colorectal, general, hepato–pancreatico–biliary, and transplantation surgery. A particular advantage of this system is the physical proximity created by locating doctors’ clinical offices within each institute, thereby helping the doctors to communicate easily about clinical and administrative issues. Thus, a patient who has been referred, for example, to an internist, can often also see a surgeon on the same day, saving the patient from multiple visits for evaluation of the same medical problem.

The institute system reduces competition for patients among physicians in different departments who perform the same procedures, because many now work together within institutes. Accordingly, the patient will be referred to the doctor who is most skilled and available for the treatment that the patient requires. The scheme has reduced the amount of fragmentation, which is inherent in a medical center the size of the Cleveland Clinic with 2,100 medical doctors and 56 psychologists with PhD degrees who have clinical responsibilities in Cleveland.

The institute structure also provides systems that are more efficient than those typically used in conventional arrangements. Department chairs in most medical schools report separately to several people, especially the dean and hospital director. In the institute system, however, each chair reports to just one person: the Cleveland Clinic chief of staff, the second-most-senior executive in the Cleveland Clinic system. One of the current institute chairs, who was recruited from another AHC, said that he reported to five people in his previous job. He commented that reporting to only one person at the Cleveland Clinic is “very liberating.”2

The institute system enables the leaders, according to one clinician, to “deal better with turf issues, since their work is better aligned.”3 Patients benefit from this alignment because doctors from different disciplines can evaluate them more conveniently. The new system has also facilitated collection of data into a comprehensive computer system and has encouraged academic collaboration within the Cleveland Clinic. Leaders at the clinic cite the advantages of reporting to an institute director who specializes in one’s area of expertise rather than to a department chair in a different field. For example, in a traditional AHC structure, a chief of the division of endocrinology might report to a chair of a department of medicine who is a cardiologist.

Because financial management has been transferred to the institutes, the institute directors and the clinic’s representatives from central administration can exercise significant control over allocation of resources, including capital budgets. Cleveland Clinic leaders hope this more centralized approach has a positive effect on financial results, but it remains to be seen whether the new structure will save money.

The leaders of the Cleveland Clinic believe that their institute system is an improvement over the traditional AHC organizational structure for physicians, patients, administrative relationships, leaders, and potentially to control costs.

Acknowledgments: The author thanks the Cleveland Clinic physicians and administrators whom he interviewed.

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1. Cosgrove DM.President, CEO, and Rich Family Chief Executive Chair, Cleveland Clinic. Personal communication with J.A. Kastor, November 22, 2010
2. Martin D. ChairCole Eye Institute, Cleveland Clinic. Personal communication with J.A. Kastor, February 18, 2011.
3. Nissen S. ChairDepartment of Cardiovascular Medicine, Cleveland Clinic. Personal communication with J.A. Kastor, December 2, 2010.

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© 2012 Association of American Medical Colleges