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Visits to IRMC’s four suitors start with Cleveland, Orlando

Photo: IRMC and Hospital District board members touring Cleveland Clinic.

An arduous schedule of travel and meetings wrapped up Tuesday as Indian River Medical Center officials toured eight hospitals in four days.

They visited two campuses – the health system flagship, and a recently acquisition – for each of four prospective partners vying to take over Vero’s community hospital. IRMC officials will make their decision about who to partner with near the end of this month.

Keeping straight the swirling images of hospital corridors and conference rooms will be of critical importance in the days ahead as board members and trustees meet to discuss their impressions and make their final choice.

Four Indian River Hospital District trustees and four IRMC board members made the tours, with two or three more joining by conference call at District offices in Vero.

The first leg of the tours began last Thursday with Cleveland Clinic’s stunning main campus in East Cleveland, in tandem with its relatively recent acquisition, Akron General. Cleveland Clinic’s main campus is a world-renowned academic and research center focused on treating high acuity patients.

The rest of the 10 hospitals in its system, including Akron, are community hospitals like IRMC, with a total of $8 billion in revenues and 53,000 employees. As stunning as the Cleveland campus was, Vero officials saw a much more down-to-earth facility in Akron, its homey atmosphere little changed since it was bought just over two years ago, though Cleveland Clinic has invested nearly $50 million in a nearly completed new emergency department. 

Immediately after seeing the Ohio hospitals, officials flew back to Vero and got up the next morning to drive to Orlando. There, they toured two hospitals of Orlando Health, one of Florida’s top healthcare systems.

IRMC’s leaders saw the flagship hospital, Orlando Regional Medical Center, a large teaching hospital in downtown Orlando, and a second hospital purchased from a Health District five years ago, Health Central, in Ocoee.

With its endless accolades, elite appeal and mind-boggling design, Cleveland Clinic showed its partnering downside quickly last week. The main campus, ranked second-best in the nation by U.S. News and World Report, with 13 specialties ranked in the top 10 in the nation, may have the aura of a fine art museum, and it certainly has some of the most celebrated physicians in the world. But it is far away from Vero Beach, Florida. Pity the Vero official who has a winter meeting of the board there.

It was so cold in Cleveland during the visit that the snow-edged sidewalks on the vast hospital campus were virtually deserted, most everyone opting for the heated glass-walled skywalks connecting one building to another.  A helpful PR executive reached out by text to offer hats and gloves for any ill-equipped Floridians.

In black SUVs, the Vero group arrived at the main entrance of the C-shaped, glass-front building, just across from a signature feature in the landscape: a tree-lined rectangular pool, its neat rows of boulders emerging not from water but from snow.

Cleveland Clinic sees the highest-acuity patient population in the U.S., “the sickest of the sick,” and during the visit it was impossible not to imagine the suffering or improvement, the fear or hope of the people passing through its halls.

Caring for those patients, thousands of whom travel from much further away than Florida (the Clinic boasts medical translators in dozens of languages), as well as for patients at Cleveland Clinic’s nine community hospitals and other healthcare facilities, is the task of some 53,000 employees.

How IRMC patients and employees would fit into that matrix dominated the discussion Thursday.

In the elegant executive offices, the Vero group pulled off jackets and greeted top hospital officials, some familiar from their own December visit to IRMC. Missing among them was the recently retired Dr. Toby Cosgrove, perhaps the best-known hospital CEO in the country.

Cosgrove had much to do with the current look of the clinic, the color, or lack of it (staff calls it 50 shades of white), the soaring spaces, the carefully crafted minimalism that extends to keeping monitoring equipment out of sight in patient rooms and hiding the power outlets in the conference room behind a back-lit floating wood panel. Instead, the eye is drawn to contemporary art of a caliber high enough to warrant free guided tours on request.

Cosgrove’s recipe for serenity is but one component in the clinic’s singular focus on the patient, a drastic, system-wide evolution still in play that extends from medical treatments – care paths, in the vernacular of forward-thinking health systems – to wider drop-offs at the main entrances to accommodate more cars at once – “Patients don’t want to wait in lines,” said one staffer.

And professionals don’t want to work in silos, corporate-ese for divisions and departments. Beginning in 2006, Cosgrove tore down those designations and changed the clinic from a profession-oriented institution to one that focused on patients and diseases. In so doing, he opened “collaboration between physicians and nurses, education and research,” said Brian Donley, the Clinic’s COO.

“It seemed very destructive at the time, because we changed the entire structure of the entire enterprise on a very short notice, but it was actually warmly welcomed by all providers,” said Tomislav Mihaljevic, a cardiothoracic surgeon, and since Jan. 1, the Clinic’s CEO – the Vero visit was on his first official day at the office as CEO. He joined the clinic in 2004 and witnessed the change under Cosgrove.

“They rallied around those two words: patients first,” continued Donley.

 The new “matrix” environment allowed input across multiple specialties and care levels to exchange opinions and information about a single patient. So critical was the shift that it put the brakes on a new cancer center, designed with the old mode of silos of care – radiation, oncology, etc. “Five years ago, we were about to put the shovel in the ground,” said Ann Huston, chief strategy officer.

“We realized we didn’t have the care model yet, and we put it on hold for two years while we actually built out those programs.” Now, the design of the cancer center “supports that interdisciplinary work. They live as interdisciplinary teams; they’re not in functional silos anymore. That speaks to the commitment of patients first, and to always challenging how we do, and what we do, and making sure it’s the best that it can be.”

Standardization of care was another theme in Cleveland Clinic’s transformation. “If you standardize anything, you always improve,” said Donley “Every time you get better quality and safety, the cost is less. It all goes together.”

That standardization and patient-first philosophy trickles down to its growing list of community hospitals, with nine in northeastern Ohio (a 10th, in Union, Ohio, is expected to be announced any day), and one in Weston, Florida, west of Fort Lauderdale.

It would also trickle down to Vero Beach, were the Cleveland Clinic to take over IRMC. But Vero would not be long alone as Weston’s companion facility. Instead, it would be only the start of a Florida expansion.

“We are contemplating an analog” to the northeast Ohio cluster of Cleveland Clinic hospitals, said Huston. Asked for a timeline, she said the expansion would come “in short order . . . within the next couple of years.” 

“If it were under our control, it would be last week.”

Vero doctors know the best-known of Orlando Health’s nine owned, leased or affiliated hospitals is outstanding. ORMC, as the sprawling downtown Orlando flagship is known, tied for a ranking of fourth in Florida by U.S. News. That hospital and three others in the Orlando Health system – Arnold Palmer Children’s Hospital, Winnie Palmer Hospital for Children and Babies, and Dr. P. Phillips, a general hospital like ORMC – were named Top Hospitals by Leapfrog, a widely-known group that acts as an industry watchdog and monitors safety and outcomes.

There are stunning buildings at the Orlando hospital and at the Health Central campus in Okoee, where officials of capital-starved IRMC eyed with envy $100 million in new construction.

What Vero doctors also know, or at least have heard, is that Orlando Health supports its physicians.

Last Friday, when Vero officials toured the healthcare system’s flagship, ORMC, Orlando Health’s relatively new CEO, David Strong, was given considerable credit for changing the culture of a system that itself was considering partners just a few years ago; it ultimately decided to heal itself and has greatly expanded since, doubling in size. Strong now oversees some $3.8 billion in revenues.

One major draw for physicians, including the hundreds who work at the hospital but remain independent, is Strong’s openness and inclusiveness when it comes to key decisions. 

He amused IRMC visitors with a story of a recent strategy session in which he involved more than 2,500 people “in deep ways” by making up a board game of potential projects.

“We gave people Monopoly money and the list of projects and they had to decide how to allocate it,” Strong told the Vero group. “In doing so, we disclosed the big rocks of our strategic plan, but what we traded in confidentiality we got back in engagement.”

Even little decisions can make a difference. When it came time to decorate the walls of the orthopedic wing, nurses and doctors got to choose the framed photos. And in the Orlando Health/UF Health Cancer Center, patients painted their own concept of the protons used to attack their tumors. Those paintings now line one hallway of the 15,000-square-foot building, some of it underground and with four-foot concrete walls, housing the proton accelerator.

The facility cost $25 million, and the ability to offer proton therapy is a source of pride to Dr. Mark Roh, a world-renowned liver cancer surgeon who is president of the cancer center.

It was Roh who led Vero visitors past the wall of paintings, accompanied by small photos of the artists and brief descriptions of their battles.

The placement of those paintings on the wall, small in comparison to the decision to acquire the innovative device they celebrate, speaks to the emotional heart of Orlando Health.

In evidence also at its earlier Vero presentation, the empathy, humility and respect officials showed seemed to pervade the system’s approach to healthcare.

Whether those intangibles could sway IRMC officials, they appear to have affected at least one vote by a trustee of a different health district, this one in West Orange County. It was that district that three years ago chose Orlando Health over much larger offers by other health systems to take over its Ocoee hospital, Health Central.

Carolyn Karraker, a former school principal and associate school superintendent is now a member of Health Central’s board of directors. She spoke to Vero officials Friday of her vote as a District trustee.

“For me, it was the culture,” she told the group. “Some people had a whole lot of flashy money and that was tempting. But I voted my comfort level. It had to do with relationships, people you knew you could pick up the phone and call and get it right.

“I got so many calls from physicians, and it came down to the people and were they accessible. I knew from the people I met that if there was a problem, I knew where to go and they would want to fix it. And I didn’t know with the other two. The chain of command was very unclear.”

Today, Health Central officials told IRMC visitors, the hospital had fully integrated into the system’s culture of top-to-bottom inclusion. Physicians, often considered the most intransigent in aligning with a corporate cultural shift, instead have been positioned as the cornerstone of quality in patient care. It was the same thread as in Orlando Health’s first presentation in Vero, when an Orlando orthopedic surgeon not employed by the hospital system breathlessly expounded on Orlando Health’s inclusion of physicians’ needs and suggestions.

Orlando Health’s board of trustees chair Sandy Shugart put it this way, answering a question from Vero vascular surgeon and physician representative, Pranay Ramdev, who was on the tour.

“A lot of healthcare systems think their physicians are problems to be solved, or a variable in the algorithm rather than a solution,” he said. “We’re interested in you [the doctors] because we think you already care about those things we care about.”

That philosophy extends to the partner hospitals as a whole. “If we didn’t have alignment in those core ideals, how would you collaborate in a disciplined way?”

Those partners could one day extend well beyond central Florida, into not only the rest of the state but in the southeast regionally, as far as North Carolina, Orlando Health officials told the Vero group.

“We’re not shopping generally,” he said with a level eye cast to Vero officials. “We’re interested in those people that share those central ideas.”

There was no stronger feeling of connection, though, than when Orlando Health showed a video on the hospital’s response following the Pulse nightclub shooting in June 2016. ORMC’s Level One trauma center, the only one in central Florida, was just blocks away from Pulse; of the 35 victims who made it there alive, all survived.

That unimaginable feat, the effort it required, and the counseling that followed the very next morning and would eventually include 2,000 ORMC staff members – earned the hospital great praise in the Orlando community, and in emergency rooms nationwide.

The video and its visible effect on the still-traumatized hospital leaders, brought the already heartfelt session to a near-halt. “I want to applaud. You are heroes,” said District Trustee Karen Deigl, breaking the long silence as guests and officials, including several doctors, worked to regain their composure.

“We debated long and hard about showing it,” said CEO David Strong, finding his voice. “Our intent was to show you part of the fabric of who we are.” He said the video has been shown 200 times around the country as part of a mass-casualty preparedness seminar given by ORMC clinicians, including a presentation at an HCA hospital in Las Vegas just two weeks before the mass shooting there.

“What we accomplished that morning, we’re still kind of overwhelmed by,” said Dr. Michael Cheatham, a surgeon and chief surgical quality officer at ORMC. At Strong’s impromptu designation, Cheatham served as media spokesperson after the shooting. “It shouldn’t have gone that well. I think it was directly connected to the fact that our family went 120 percent. That’s just the culture here. That’s what drew me here and keeps me here.”

Ahead: Next week, coverage of IRMC visits to HCA hospitals in Aventura and Miami, as well as Adventist Health System’s Florida Hospitals in Orlando and Daytona.

The District Board meets on Thursday, Jan. 17 to “debrief” the trips. The IRMC board is expected to do the same on Jan. 22. Consultants from Juniper Advisory will be present for both meetings. Then, on Jan. 30, Juniper will present to both boards the results and summary of the second-round proposals. Following that meeting, the two boards will meet separately to come up with a recommendation. “Hopefully both boards will come up with the same suitor,” said Cunningham.