Conversations about how to improve healthcare delivery tend to pay a lot of attention to innovation and the need for futuristic thinking.
This is especially true in the context of how healthcare services the world over can meet some of the biggest challenges they currently face — growing populations, aging populations, and more immediately, the COVID-19 pandemic. The assumption is that to move forward, we have to look forward and think new.
But if we look around us, there are examples of healthcare delivery that are already doing a good job at meeting the manifold challenges of the present and have been doing so for quite some time. Why would we assume these wouldn’t continue to work in the future?
That’s the thing about public health administration and the organization of medical services — it is far from a uniform approach, there are countless different examples already in play all over the world, most of which have their merits. Before we get too lost in blue-sky thinking, maybe we should be evaluating what we already have and finding out what we can learn from them.
Acting as a unit
One example which rightfully gets plenty of attention is multidisciplinary care. As concept and practice, there is nothing at all out-of-the-box or radically groundbreaking about multidisciplinary care. In fact, it is already a well-established part of the medical mainstream, with many hospitals utilizing multidisciplinary teams (MDTs) as dedicated units for treating patients with the most complex care needs.
And yet there is another approach to multidisciplinary care that takes the notion of cooperation and coordination across traditional disciplinary boundaries much, much further. As practiced by the likes of The Cleveland Clinic, The Mayo Clinic, and Northwestern Medicine, all based in the USA, the multidisciplinary approach is not just another department with its own roles and responsibilities. It’s a principle that underpins the care of every patient.
The three institutions named above make for a distinguished list. All are internationally renowned for their clinical as well as academic excellence. The Mayo Clinic and The Cleveland Clinic rank number one and two as the best hospitals in the US, The Northwestern Memorial Hospital, Northwestern Medicine’s flagship, tenth.
Surely there is something in their common approach which healthcare providers across the board should take notice of?
What is remarkable is that the model of multidisciplinary care Cleveland, Mayo, and Northwestern represent is by no means new. In fact, it predates many of the innovations in medicine and in administration that we now take for granted as defining features of modern healthcare. The Mayo Clinic traces its history back to 1889 when Dr William Worrall Mayo and his sons helped to found St Mary’s Hospital in Rochester, MN. When the Mayo family practice started to expand its horizons and invite eminent specialists in a number of fields to work with them, it is credited to have pioneered the concept of ‘group practice’. Right from the very start, integration of expertise was central to their vision.
It’s a similar story with the Cleveland Clinic. When physicians William Lower, Frank Bunts, George Crile Sr., and John Phillips founded it in Ohio in 1921, their guiding philosophy was one they had learned on active military in Europe in the aftermath of World War 1 — “to Act as a Unit”, or in other words, to break down the disciplinary and departmental silos that had already started to define medical administration.
James K. Stoller, chairman of the Cleveland Clinic’s Education Institute, explains how the philosophy of unified purpose has translated into practice at the Clinic over the course of the last century:
“The group practice of medicine is elegantly realized at the Clinic; colleagues collaborate and are vigorously and authentically available to each other in the mutual care of their patients… Transparency in the clinical work of the Clinic is paramount, e.g., as demonstrated by the yearly publication of outcomes books by each institute which contain non-risk-adjusted outcomes.”
In this model, collaboration and transparency across departments, coupled with a collegiate approach to learning, goes far beyond having a dedicated multidisciplinary team in place for cases showing the most complex comorbidities. It is the defining ethos of the entire establishment, hard-baked into the organizational structure, and governing the delivery of all services.
The Cleveland Clinic has in more recent times invested heavily in systems which enable universal data sharing across the whole institution and was one of the first healthcare providers in the US to implement a structured approach to care coordination, in the form of a ‘Patient Service Navigator’ which also treats the patient as part of the collaborating team.
The objective? Nothing short of offering end-to-end holistic care, or care which treats ‘the whole person’ rather than just the list of symptoms. Especially in the context of rapid population growth, rising life expectancy, and increasing demands on health services, with the pressures that creates to tip the balance from interventionist towards preventative approaches, this is surely a model that deserves wider consideration as a solution to 21st century problems.
A broader perspective
So what is it that makes this holistic multidisciplinary model so successful, and how can it be imitated? The Mayo, Cleveland, and Northwestern all share a certain common set of characteristics that we can only conclude contribute to their success. One thing that stands out above all else is the tight-knit integration of clinical, educational, and research operations across all three institutions.
Stoller writes that The Cleveland Clinic was founded with a ‘tripartite mission’ in mind. Alongside the delivery of medical care, it is also committed to investigating the causes of illness (research), and improving the knowledge and skills of practitioners (education). One of the pillars of Northwestern Medicine is the Northwestern University Feinberg School of Medicine. A significant percentage of the 4,400 physicians employed by the group work in faculty and research roles out of the Feinberg School. Similarly, the Mayo Clinic operates massive medical training and research programs alongside its clinical operations.
We might say, then, that the multidisciplinary model as exemplified by these three institutions is dynamic. As well as being founded on a principle of drawing together expertise across traditional disciplinary lines in a robust, structured way, it is also based on continuous learning and improvement, on robust academic research to push back the boundaries of our understanding of disease, on world-class education and training to share knowledge and best practice. In such an environment, nothing is ever allowed to stand still. Knowledge drives both innovation and continuous critical examination of what constitutes best practice and quality of service.
There is another element to this model which should make all healthcare providers sit up and take notice. Not only do the Mayo, Cleveland and Northwestern achieve world-class results across a broad range of medical specialisms while pursuing an unwavering commitment to multidisciplinary care, medical research, and education, they also manage to drive down the costs of care.
How is that possible? It all boils down to efficiency. The standard departmental silos you find in most hospitals are inefficient. If your focus is on treating only a narrow set of symptoms, you miss opportunities to understand the underlying causes, you miss insight into what other health problems that individual might run into further down the line, you create the conditions for long-term reliance on interventionist care.
Structured multidisciplinary collaboration and universal data sharing means, as Stoller writes, that “fewer diagnoses are missed, problems are caught earlier, and costly complications (which drive the bulk of healthcare spend) are prevented.” By delivering care services for practically any condition or disease “under one roof”, you shorten and speed up the patient journey through diagnosis and treatment. This becomes especially apparent when a patient faces a complex range of co-morbidities — instead of being bounced around a string of referrals, a robust multidisciplinary approach means one point of examination, one point of diagnosis, a single treatment plan.
Finally, a robust approach to knowledge sharing and skills development also leads to fewer variations and improved outcomes, meaning patients have to return for further treatment less frequently.
Faced with unprecedented resource pressures and the increasing recognition that conventional models of healthcare organization are no longer able to cope, authorities the world over could do a lot worse than revisit the holistic multidisciplinary approach for inspiration. The Mayo Clinic, The Cleveland Clinic, and Northwestern Medicine amongst others exemplify the foundations for clinical excellence and continuous improvement based on a culture of open knowledge sharing.
The holistic approach, underpinned by world-class research and education, means that these institutions are geared to identifying and treating underlying causes, not just the symptoms of disease. This ultimately pushes towards a preventative, not just interventionist, approach, increasing efficiency of care, and patient outcomes while reducing long-term reliance on care services.