How Toby Cosgrove engages employees to expand The Cleveland Clinic while keeping patients first

When Dr. Delos “Toby” Cosgrove took the reins as president and CEO of The Cleveland Clinic four years ago, he wasn’t just a world-renowned heart surgeon stepping into a new role. He was also a leading doctor about to take a leading hospital to a whole new level of excellence. For 14 straight years, U.S. News & World Report has recognized The Cleveland Clinic as the No. 1 heart hospital in the country, and last year, the hospital finished as the overall No. 4 hospital in the country, with 10 of its specialties being ranked in the top 10 by the report. “We’ve had an enormous growth over the last decade, and I think the growth has been secondary to a recognition for the quality of the product that we produce,” Cosgrove says. “Unless you’re producing an excellent product, there isn’t a lot of demand for your services. The excellence that The Cleveland Clinic has been known for, both locally, nationally and internationally, has created increasing demands for our services.” With more demand being placed on the organization, Cosgrove couldn’t simply coast by resting on the clinic’s laurels. Instead, he has pushed his executives, managers and doctors to innovate and find ways to make the things that were already great even better. His doctors have continued cutting-edge research and pioneered new procedures. He’s also expanded the clinic by establishing hospitals in Toronto and another to open in Abu Dhabi in 2011. And last fall, the clinic opened up The Sydell and Arnold Miller Family Pavilion and the Glickman Tower in Cleveland to house its Heart & Vascular Institute and the Glickman Urological & Kidney Institute. Big ideas also require big budgets. All of these projects and expansions wouldn’t be possible if Cosgrove didn’t keep the financial side running well, which he has, as the clinic’s total 2007 operating revenue climbed to $4.8 billion from $4.4 billion the year before. Despite everything he’s done to take the clinic to that next level of excellence, Cosgrove also wants his people and the community to know that while he has big ideas for the future, he is also grounded in reality. While the keys to successful growth have been to create a plan, lead people through the changes and track the progress, you also have to stay grounded in your core values and reasons for existence. “I started out four years ago, when I told in my initial talk to the community, that it’s the only reason that we’re here is for patients and patients come first, and everything flows from that,” he says. “The reason that we’re building these facilities is for patients. It’s not for doctors. It’s not for administrators. It is for patients. You have to keep your core values as your anchor, and once you have those established, then everything else flows from there.” Create a plan Before Cosgrove could put a new plan in place, he surveyed the situation. “We went and looked at all of our physical facilities all over Northeast Ohio,” Cosgrove says. “Then we looked at what was good of our physical facilities, what was not so good of our physical facilities, and then we began to figure out what we needed to do.” In looking at the different facilities, Cosgrove discovered that some of them were OK, but he also realized some were getting older and needed investment in them to bring them up to current standards. He also found that some facilities were so old that it wasn’t worth investing in them anymore. Then he began to couple the physical facility needs with those of the patients. He looked at how the clinic could better meet patient needs with the facilities it currently had, and how, going forward, it could meet the needs of the community and its patients. “We spent a lot of time projecting out into the future what the population needs were and what the new technologies were going to be and how we could best serve those needs,” he says. While nobody has a crystal ball to see what the future holds, Cosgrove says you can still make educated assumptions by looking at as many sources as possible. “You have to get as many points of view and as much input as you possibly can and understand where your particular industry is going,” he says. “That includes understanding demographic changes, understanding, in our case, disease trends, but it would be trends in any industry, understanding population shifts in your particular area, and understanding what people are looking for in terms of the population’s desires and expectations.” From looking at all the data, Cosgrove and his team created a campus plan that looked at where the clinic wanted to be five and 10 years out, and they explored options for getting there. The team created one scenario, and then would try it out with multiple people in the organization, and then it tried another and another. “We just kept going back to it until we found a scenario that fit most people’s expectations,” he says. When it comes down to it, you have to rely on these other people, but combine it with your own ideas. “Obviously, you have a body of experience of things you’ve done yourself in the past, so you bring that to the table,” Cosgrove says. “Then you get a lot of input from other people.” Once Cosgrove had an idea of where he wanted to take the hospital, he then had to create a strategic plan, which encompassed that campus plan, to get there. When you’re creating a plan, you have to be grounded in reality of what you can do. “There’s any number of ways that you have to go and check the reality of what you’re capable of doing,” he says. “When you start down a road, it’s just constant checking — can you get to the end of that road? A journey of a thousand miles starts with a single step.” He knew a few things already: That the clinic’s main campus wasn’t leaving Cleveland, that it was going to be a very high-tech hospital, and that it had the highest acuity (a measure of the average severity of illness in patients) of any hospital in the country. “Now, all of those go to form part of the plan,” Cosgrove says. For example, he would need a lot of employees on-site, and that meant he’d have to accommodate them in terms of parking and seating and making the campus employee-friendly. “All of those came from the fact that we made the basic decision that we were staying here in a major hospital presence,” he says. “Each one of those was sort of a cascading decision.” He says that where you go all stems from basic decisions. “Look at where your industry is going, what your portion of the industry wants to be and what niche you want to fill,” he says. “I think every leader has multiple options and needs to decide the things we want to do and the things he doesn’t want to do.” For example, one of the things Cosgrove decided to do was to take obstetrics off of the main campus. He saw that the suburbs were where the majority of the babies were being born, so that’s where the specialty should primarily be located. He also decided to consolidate the clinic’s psychiatric services, and it was better for those services to also be off of the main campus. Additionally, he decided to change how care was organized. Instead of having the usual departments of medicine and surgery, he went to institutes built around organ and disease systems — a cardiovascular institute, a neurological institute and a urologic institute. This allowed the medical and surgical expertise to be in one location, and that also affected the buildings by bringing all the expertise into one physical location. In short, he made big changes. Cosgrove says, “There’s a lot of people here, so change is still always difficult.” Lead people through change When it comes to change, most people aren’t too fond of it, so as Cosgrove took all 37,000 of the clinic’s people through these changes, he stuck to a couple of key principles. “There are two things that help people through change,” he says. “One, involving them in making a plan and understanding the plan, and two, constant, constant, repetitive communication. It takes multiple communication venues in order to get that message across. The more you do it, the more people feel comfortable with it, but involvement in the planning is essential.” Cosgrove involved hundreds of people at every level of change. For example, with the Miller Pavilion, he had nurses help him with planning the nurses’ units. He had mock-ups of the operating rooms, and then he’d have all of the surgeons come in and give their input. He did the same thing with the intensive care unit and did a mock-up of the cath labs and had the cardiologists come in and give their input. Additionally, he traveled to what he thought to be the best facilities to get ideas and feedback. He hired top architects and landscapers. He also talked to food service people and volunteers, and he enlisted consultants and industry experts and got opinions on everything even down to the chairs and beds. Lastly, he talked directly to the patients. He held focus groups with them to see what amenities they wanted to see in the facility and how it should feel and look. “The more people that are involved, the more they have the buy-in, and the more they’ll help, and it’s a multiplier effect,” Cosgrove says. “The multiplier effect comes if it’s your plan — you’re going to go out and sell it.” In addition to involving people as you make the changes, you also need to make sure you’re communicating with them. “I talk to multiple groups every single day,” he says. “It seems like an awful lot of my time [is spent] just talking to people.” Cosgrove communicates with his employees through various venues. He does it in large group settings, small groups, print, television, in-person and through Web sites. “People get their information in different ways, and you have to go to multiple roots to deliver the message,” he says. As you continue to communicate and work your way through, it’s important to also share in the success with your people. “At the end of the success, you celebrate,” Cosgrove says. “As people see success come and they have an opportunity to celebrate success, I think they’re ready for more of it. [It’s] adrenaline. Everybody likes adrenaline, reward and recognition” The Cleveland Clinic had a weeklong celebration in September to commemorate its new facilities, and it even invited all 3,000 of the people who worked on the new facilities and their families to attend. Cosgrove recognized that as more people and employees saw the facilities and saw the future of the organization, they got more excited about it, but again, he says to stay connected to what your core is and not lose yourself in that excitement. “The buildings, the campus, the strategic plan, all hinge around that individual patient and the quality of the care that we deliver for that patient,” he says. “We’ve never lost sight of that, and that has been the point at which we started at.” Track progress Even after creating plans, it’s important to stay close to them as you move forward. “It’s an ongoing process,” he says. “I don’t think you make a plan, put it on the shelf, and come back five years later and make another plan. It’s constantly revised and constantly updated.” With so many updates and revisions going on for those initial plans, it could be easy for Cosgrove to lose track of things, so it’s important to have metrics to gauge progress along the way. “You have to measure what you’re doing, and you begin to turn the art to the science,” he says. “Art is about feeling. Science is about measuring.” Creating metrics is something that not every organization does well, but Cosgrove has put a huge emphasis on it in leading the organization. “We have an enormous number of metrics that we put together,” he says. “That’s one of the things that health care hasn’t been good at in the past. We’ve spent a terrific amount of time now developing these metrics.” The key to determining your metrics is to look at where you’re trying to take your organization. For example, he says if you’re a for-profit business, then your main metric is simply the dollars. But when you’re a nonprofit like The Cleveland Clinic and your whole reason for existence is to help people, you have to look at other areas. For example, Cosgrove doesn’t simply know the number of patients in the hospital on any given day. He can tell you where the patients are, what they’re doing, what the trends are by how long they’re staying, where they’re coming from, what their demographics are, and how long it takes to turn over a bed from one patient to another. “We have huge numbers of demographics that we look at on a regular basis,” Cosgrove says. “Some are on a daily basis, some on a weekly basis, some on a monthly basis, and some on an annual basis, and we trend those. We measure by numbers.” He says that some metrics are just plain common sense. For example, he’d want to know every day how many people are in the hospital. But on the flip side, he can’t track employee satisfaction every day, so that’s something he’d do annually. In terms of the ones that fall in between, that comes down to how important they are. “The ability to measure and the speed with which you can respond to these measurements is the ultimate determinant of how successful you’re going to be,” Cosgrove says. “The only real competitive advantage that you’re going to have is speed.” The quicker you have that information, the faster you can respond and address problems. For example, if he has an infection outbreak in the hospital, the quicker he can find the reasons for it, the faster he can address it and stop it. “You need to be able to respond quickly and have as much information as you can as fast as you can,” he says. Out of all the measurements that Cosgrove — and any leader — utilizes, again, it’s important to keep one at the forefront more than anything — your customer. “The main thing we are here for is patients,” he says. “The only reason that you have a hospital or doctors or anybody else who works here is for patients, so the ultimate measurement of how we do is how our patients do and how they feel about what we’ve done for them.”