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Cleveland Clinic Use of Multidisciplinary Teams; Salaried Physicians Deemed Essential

Posted Jan 09 2013 12:00am

In a recent note, I began to explore ways in which the goals of hospital-based physicians and hospital executives could be better aligned (see: More on the Alignment of Hospital Physicians with Hospital Executive s). The underlying assumption is that quality care may sometimes conflict with the cost of care. In my opinion, the faster way to achieve this alignment is through the deployment of multidisciplinary teams (MDTs). According to a recent op-ed piece in the New York Times, this important goal is being accomplished at the Cleveland Clinic (see:  Approaching Illness as a Team ). Below is an excerpt from the NYT piece:

The Cleveland Clinic, 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, 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 patients need 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. 

In summary, the Cleveland Clinic has established 18 so-called "institutes" (the term sounds a little overblown) that use multidisciplinary teams (MDTs) to deliver quality care that is also less expensive. Here's a quote from my recent note about the value of MDTs as a tool for clinical integration:

[The] interests [of physicians and hospital executives] should completely align in terms of the coordination of care, alternatively described as clinical integration....One of the most effective ways to achieve coordination of clinical care is through the use of multidisciplinary teams (MDTs) that are commonly deployed in cancer centers and increasingly in other clinical settings.

Note the reference in the NYT piece above to the fact that the Cleveland Clinic has "leverage" over its physicians because they are salaried, have one year contracts, and subject to annual performance reviews. There is no question that such an organizational structure plus the relatively unique culture there enables the organization to quickly effect change. The hospital certainly has the attention of the New York Times and President Obama (see:  Cleveland Clinic Ad in WSJ, NYT Capitalizes On Debate Praise ).

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