In 2010, Cleveland Clinic's heart program was ranked the best in the nation by U.S. News & World Report for the 16th year in a row. Steve Nissen, MD, chairman of cardiovascular medicine at Cleveland Clinic's Sydell and Arnold Miller Family Heart & Vascular Institute, explains how the Institute continues to achieve spectacular rankings.
1. The institute reviews every single patient death. According to U.S. News & World Report, mortality rate is used to rank the best heart centers in the nation. Although top-ranked heart centers are judged on their willingness to accept difficult cases — and lots of them — they are also expected to keep mortality rates low. With one of the highest patient severity levels in the country at 7.2 in 2009, it is a wonder that mortality rates for cardiac surgery patients remain low at 2.7 percent. Dr. Nissen attributes this accomplishment to the institute's strict policy about reviewing all patient deaths. "The purpose of each [quality review] is to understand if there was anything we could have done better or differently. What can we learn from the loss of the patient?" he says.
The Institute could game the system, he says, by accepting easy cases to improve mortality rates. But it doesn't. The patients operated on at the institute are "among the sickest of the sick." The trick to accepting difficult cases and maintaining low mortality rates is having consistent policies in place to educate physicians on the routine for every procedure. Every procedure has an accepted set of policies associated with it, and every action is documented and measured to determine where problems lie. "Does that mean every single patient has a great outcome? No," Dr. Nissen says. "But we always try to learn something from our successes and our failures, and we review [both types of] cases."
2. Every physician is a salaried employee. Since its inception, Cleveland Clinic has refused to pay its physicians on a fee-for-service basis. Instead, every physician is compensated 100 percent with a pre-determined salary rather than a combination of salary plus incentives. Dr. Nissen says the policy prevents "turf wars" between physicians and ensures that quality patient care — not financial benefit — is the top priority for every provider. "It's a very liberating environment because it means if you have to take more time with a patient, you take more time," he says. "It's about quality rather than quantity. Rushing patients through and doing more procedures does not enhance the remuneration received by our physicians."
Employing physicians also means physicians don't hesitate to refer a patient to a colleague. "If you go into [other institutions], often the interventional cardiologists and the cardiac surgeons are at odds," he says. "That's not the case here. You can't do what's best for the patient if you're protecting your turf. You have to be willing to say, 'Somebody else is better equipped to get a better outcome.'"
3. The institute builds on its legacy of innovation. It's very hard to build a great cardiovascular program overnight, Dr. Nissen says. The Heart & Vascular Institute's legacy of innovation dates back to the late 1950s, when "eccentric" cardiologist Mason Sones, MD, accidentally performed the first coronary arteriography by dropping a patient's catheter into the corony artery and injecting dye — a procedure previously thought fatal. "The patient didn't die, so [Dr. Sones] reasoned you could inject dye into the coronaries and take pictures, and he started doing it," Dr. Nissen says. "Everybody in the world wanted to learn how to do the procedure, and he was a very gracious teacher."
The trend continued over the decades, as Cleveland Clinic pioneered the first coronary bypass surgery and then the internal mammory artery bypass graft. More recently, current Clinic CEO Delos "Toby" Cosgrove, MD, mastered the art of repairing heart valves rather than replacing them. "We've benefitted from an environment that's very conducive to innovation and technologies," Dr. Nissen says.
4. Research starts at the Clinic. Because Cleveland Clinic is an academic medical center, the physicians, nurses and administrators are right there when technologies are being developed. "We know what new technologies can and can't do, and we can adopt those that look promising," Dr. Nissen says. He says the Clinic doesn't shy away from trying out new technology. "In cardiovascular medicine, we keep a very close tab on [innovation] and if there is an emerging technology that we believe will offer better patient care, we are very likely to be early adopters," he says. Currently, the Heart & Vascular Institute is among the leading centers in percutaneous valve replacement. "A group of people saw it had great potential, got involved in the research and we became one of the first centers to use the device," he says.
5. Collaboration between physicians and nurses is encouraged. The U.S. News & World Report rankings are partly based on a hospital's nursing standards. Nearly three-fourths of the ranked facilities — including the Cleveland Clinic — are recognized by the American Nurses Credentialing Center as "Nurse Magnet" hospitals for high-quality nursing care, an honor awarded to only one in 15 U.S. hospitals.
Dr. Nissen attributes this distinction to the relationship between physicians and nurses at Cleveland Clinic, which he says is different from many institutions in the United States. Instead of adhering to a traditional hierarchy, the Heart & Vascular Institute encourages nurses to speak up when they see a problem. "If you have a mutual respectful relationship with the nursing staff, it makes an enormous difference," he says. "Occasionally a nurse will complain that a physician is [treating a nurse poorly], and I call them in and say, 'That's not how it works here.' We give our nurses a seat at the table." He says this policy attracts the best nurses in the country, and those that work at the Clinic are happy with their jobs.
6. The Clinic encourages self-education. When a physician decides to pursue an education opportunity outside the Clinic, Dr. Nissen says the hospital is very generous with providing time and paying for tuition. "We want people to be on the cutting edge," he says. "It might mean [the physician] is not as productive in terms of patient volume, but they're going to bring a new skill back to the group." He says the department has covered the tuition for a master's of public health for several employees. "Our willingness to support that kind of time is much more liberal than other institutions," he says.
7. They're ahead of the curve on EMR. Cleveland Clinic rolled out its first electronically integrated sector — the Cleveland Clinic Family Health Centers — in 2003 and has been busy implementing the Epic EMR ever since. Because the Clinic is ahead of the curve on implementation, Dr. Nissen says physicians and nurses are benefiting tremendously from the presence of the often-feared technology. "We were an early adopter, and we are much more efficient now," he says. "You're not trying to read scribbles in a chart. It's really, really paid off for us." Currently, he says the Clinic is implementing a voice recognition program for physicians who struggle with typing. "I can speak to the computer and it types the words as I speak, and that saves me about an hour a day." And those extra hours are essential when the Heart & Vascular Institute is trying to keep patient volume high while still spending quality time with each patient.
Learn more about Cleveland Clinic's Sydell and Arnold Miller Family Heart & Vascular Institute.
1. The institute reviews every single patient death. According to U.S. News & World Report, mortality rate is used to rank the best heart centers in the nation. Although top-ranked heart centers are judged on their willingness to accept difficult cases — and lots of them — they are also expected to keep mortality rates low. With one of the highest patient severity levels in the country at 7.2 in 2009, it is a wonder that mortality rates for cardiac surgery patients remain low at 2.7 percent. Dr. Nissen attributes this accomplishment to the institute's strict policy about reviewing all patient deaths. "The purpose of each [quality review] is to understand if there was anything we could have done better or differently. What can we learn from the loss of the patient?" he says.
The Institute could game the system, he says, by accepting easy cases to improve mortality rates. But it doesn't. The patients operated on at the institute are "among the sickest of the sick." The trick to accepting difficult cases and maintaining low mortality rates is having consistent policies in place to educate physicians on the routine for every procedure. Every procedure has an accepted set of policies associated with it, and every action is documented and measured to determine where problems lie. "Does that mean every single patient has a great outcome? No," Dr. Nissen says. "But we always try to learn something from our successes and our failures, and we review [both types of] cases."
2. Every physician is a salaried employee. Since its inception, Cleveland Clinic has refused to pay its physicians on a fee-for-service basis. Instead, every physician is compensated 100 percent with a pre-determined salary rather than a combination of salary plus incentives. Dr. Nissen says the policy prevents "turf wars" between physicians and ensures that quality patient care — not financial benefit — is the top priority for every provider. "It's a very liberating environment because it means if you have to take more time with a patient, you take more time," he says. "It's about quality rather than quantity. Rushing patients through and doing more procedures does not enhance the remuneration received by our physicians."
Employing physicians also means physicians don't hesitate to refer a patient to a colleague. "If you go into [other institutions], often the interventional cardiologists and the cardiac surgeons are at odds," he says. "That's not the case here. You can't do what's best for the patient if you're protecting your turf. You have to be willing to say, 'Somebody else is better equipped to get a better outcome.'"
3. The institute builds on its legacy of innovation. It's very hard to build a great cardiovascular program overnight, Dr. Nissen says. The Heart & Vascular Institute's legacy of innovation dates back to the late 1950s, when "eccentric" cardiologist Mason Sones, MD, accidentally performed the first coronary arteriography by dropping a patient's catheter into the corony artery and injecting dye — a procedure previously thought fatal. "The patient didn't die, so [Dr. Sones] reasoned you could inject dye into the coronaries and take pictures, and he started doing it," Dr. Nissen says. "Everybody in the world wanted to learn how to do the procedure, and he was a very gracious teacher."
The trend continued over the decades, as Cleveland Clinic pioneered the first coronary bypass surgery and then the internal mammory artery bypass graft. More recently, current Clinic CEO Delos "Toby" Cosgrove, MD, mastered the art of repairing heart valves rather than replacing them. "We've benefitted from an environment that's very conducive to innovation and technologies," Dr. Nissen says.
4. Research starts at the Clinic. Because Cleveland Clinic is an academic medical center, the physicians, nurses and administrators are right there when technologies are being developed. "We know what new technologies can and can't do, and we can adopt those that look promising," Dr. Nissen says. He says the Clinic doesn't shy away from trying out new technology. "In cardiovascular medicine, we keep a very close tab on [innovation] and if there is an emerging technology that we believe will offer better patient care, we are very likely to be early adopters," he says. Currently, the Heart & Vascular Institute is among the leading centers in percutaneous valve replacement. "A group of people saw it had great potential, got involved in the research and we became one of the first centers to use the device," he says.
5. Collaboration between physicians and nurses is encouraged. The U.S. News & World Report rankings are partly based on a hospital's nursing standards. Nearly three-fourths of the ranked facilities — including the Cleveland Clinic — are recognized by the American Nurses Credentialing Center as "Nurse Magnet" hospitals for high-quality nursing care, an honor awarded to only one in 15 U.S. hospitals.
Dr. Nissen attributes this distinction to the relationship between physicians and nurses at Cleveland Clinic, which he says is different from many institutions in the United States. Instead of adhering to a traditional hierarchy, the Heart & Vascular Institute encourages nurses to speak up when they see a problem. "If you have a mutual respectful relationship with the nursing staff, it makes an enormous difference," he says. "Occasionally a nurse will complain that a physician is [treating a nurse poorly], and I call them in and say, 'That's not how it works here.' We give our nurses a seat at the table." He says this policy attracts the best nurses in the country, and those that work at the Clinic are happy with their jobs.
6. The Clinic encourages self-education. When a physician decides to pursue an education opportunity outside the Clinic, Dr. Nissen says the hospital is very generous with providing time and paying for tuition. "We want people to be on the cutting edge," he says. "It might mean [the physician] is not as productive in terms of patient volume, but they're going to bring a new skill back to the group." He says the department has covered the tuition for a master's of public health for several employees. "Our willingness to support that kind of time is much more liberal than other institutions," he says.
7. They're ahead of the curve on EMR. Cleveland Clinic rolled out its first electronically integrated sector — the Cleveland Clinic Family Health Centers — in 2003 and has been busy implementing the Epic EMR ever since. Because the Clinic is ahead of the curve on implementation, Dr. Nissen says physicians and nurses are benefiting tremendously from the presence of the often-feared technology. "We were an early adopter, and we are much more efficient now," he says. "You're not trying to read scribbles in a chart. It's really, really paid off for us." Currently, he says the Clinic is implementing a voice recognition program for physicians who struggle with typing. "I can speak to the computer and it types the words as I speak, and that saves me about an hour a day." And those extra hours are essential when the Heart & Vascular Institute is trying to keep patient volume high while still spending quality time with each patient.
Learn more about Cleveland Clinic's Sydell and Arnold Miller Family Heart & Vascular Institute.