The Cleveland Clinic, Leadership Powerhouse



The Cleveland Clinic, Leadership Powerhouse

A new CEO is taking the reins at one of America's top health care institutions.

Something important happened recently at one of America's most successful and respected health care institutions. After a disciplined selection process, leadership of the Cleveland Clinic is transitioning from Floyd Loop, M.D., to Delos (Toby) Cosgrove, M.D. Under Loop's direction, the Cleveland Clinic emerged from a close scrape with financial disaster 13 years ago to become a powerhouse whose future prospects Cosgrove now describes as "endless." During that period, the Cleveland Clinic's revenues grew from $636 million to more than $3.6 billion, and the clinic transformed a desperately declining neighborhood into an international showcase of medical capability.

Loop grew up in a small town in Indiana, and like many of the men who built clinical empires around heart surgery, he sharpened his skills in the military. In 1968, he made his way to Cleveland and the clinic. Not only did he make dramatic contributions to the volume and prestige of heart surgery at the Cleveland Clinic, he reinvented the way heart surgery was performed throughout the world. He eventually found himself on the clinic's board of governors, the all-physician leadership team that makes the institution's most important decisions.

The financial difficulties the clinic faced in the late '80s was partly due to its expansion into Florida. Losses there were robbing the clinic of its ability to grow in Cleveland. A prestigious consulting firm recommended selling the Florida operations. The clinic's CEO resigned. Loop got the job. He felt the clinic lacked vision, so he drafted a plan and went to work on making it a reality. At his first presentation to his colleagues as CEO, Loop outlined his strategies for recapturing the financial viability of the clinic. And, to the surprise of many, he announced he was keeping the Florida operations. In his first year, he engineered a $60 million turnaround.

Filling His Shoes

When I met with Loop earlier this year, he told me that the following day the selection committee, formed to pick his successor, would have its first meeting. He had thought a great deal about succession. This was no ordinary succession because this was no ordinary organization. From the beginning, the Cleveland Clinic has been unique. Founded by surgeon George Crile and his three partners, the Cleveland Clinic was committed to the notion that teamwork and collaboration were essential to meeting the complexity and uncertainty that characterized medicine. In their minds, not only would group effort be fundamental to good clinical care, it would be the cornerstone of research and teaching.

The founders of the Cleveland Clinic committed their enterprise to "act as a unit" and then contributed their personal wealth to endowing its nonprofit purpose by transforming it into a foundation. From that point forward, no assets of the Cleveland Clinic would accrue to the benefit of private individuals. All physicians and all employees would be salaried. There would be no incentive compensation. And physicians would lead the clinic, as the founders believed physician leadership was best for a medical enterprise.

The uniquely egalitarian enterprise that resulted came to be described by those inside it as "our medical model." It was a model in which distinctions between hospital and physician practice did not exist. It is all one thing. Loop never failed in his speeches or his writings to emphasize that he and everyone else at the clinic were mere stewards of a great institution: "Each member of the organization is a guardian of this enterprise and is responsible for ensuring that the Cleveland Clinic is synonymous with the finest health care in the world." Nor did he fail to recognize what made it great--what he described as "a commonwealth of intellect, a republic of ideas, and the best example of physician-managed health care." It was the CEO's job to strengthen, enrich and expand that great republic.

Loop had his thoughts on succession typed on two sheets. He handed them to me and asked that I not share them until after the selection had been made. At the top of the first sheet was this simple statement of purpose directed to those on the selection committee: "You are searching for the chief executive officer for one of the great health care institutions in the world." On the pages were his thoughts as to the kind of person the new CEO should be and how he or she should spend time. Loop's stature within the clinic was such that what he had written would surely shape the decision. Among the items on his list were "preparation, including two hours daily reading to support writing, speeches, strategy ideas, counsel and mentoring." He also emphasized clear vision, both "intuitive and decisive," serving as a "chief strategist" and having "a sense of urgency." And he shared these keys to effective leadership:

• It doesn't do any good to be a dreamer unless you follow through.

• There are two kinds of people in this world: those who want to be somebody and those who want to do something.

• You have to have a strategy, not something you hope for, but something you work for.

• Better plan to be optimistic, never despondent.

• It is not within the power of the properly constructed human mind to be satisfied ... the greatest joy in life is to accomplish.

• Napoleon said that the greatest characteristic that a soldier could have was not courage; it was stamina.

• Don't forget that clinical medicine comes first.

It was a given that the candidates would come from within the clinic. To Loop's credit, the clinic has a rich pool of talent to draw from. All of the candidates were seasoned, respected not only for their leadership qualities but also for their outstanding reputations as clinicians, researchers and teachers. Each candidate made two presentations to the selection committee. The first presentation focused on why they were right for the job; the second presented their vision for the clinic.

A Beating Heart

At one point, I had asked Loop how heart surgery had shaped his strategic decision-making. He asked whether I'd ever seen an open-heart procedure, and when I said no, he invited me to observe one. Loop had stopped performing surgeries three years before, so he said he would line me up with somebody. That somebody was Dr. Toby Cosgrove.

The patient and the surgical team were waiting for Cosgrove when I got to the OR. The young surgeon who was assisting was inquisitive and outgoing, but he commented that the climate in the OR would change when Cosgrove got there. He would set the tone. And so he did. Things got much quieter when he walked into the room. He introduced himself and told me that although I could watch the procedure on the TV screen above, I would see better if I watched over his shoulder. Stacking step benches were placed against the back of his legs. I stood on them looking down on the surgical field. "You really need to drape yourself over me to see," he said. So I did.

Cosgrove had pioneered minimally invasive heart surgery, and on that day he worked through a 3-inch incision in the patient's chest. Within that small hole, I could see something moving: The patient's heart was beating. She had a damaged valve, and Cosgrove and his team were going to rebuild it. The patient's heart was then stopped so they could begin their work. Cosgrove reached for a retractor. In this OR and ORs throughout the world, it was called a Cosgrove retractor. He had fashioned it after a bicycle hand brake. The small hoop that would give structure to the repaired valve also had a name. It was a Cosgrove Annuloplasty System--he had based its design on an embroidery hoop. These devices were only two of Cosgrove's 18 patents.

Someone had suggested to me that the most remarkable part of the surgery would be the moment the heart started beating again. And that was remarkable. But, for me, even more remarkable was watching Cosgrove's fingertips flutter as they sutured in motions so quick they were hard to see.

As Cosgrove walked to the podium to address his colleagues in a dramatic gathering shortly after the announcement of his selection, rows of men and women in white lab coats rose and began to clap slowly, then thunderously. In the front row stood and clapped each of the physicians who didn't get the job. Here was a man both respected and loved. It was he, after all, who had placed above the elevators leading to the ORs in which he and his team operated a sign that read: "Through these portals pass the world's greatest cardio thoracic surgical team." There were important things about the man at the podium the audience would not learn until a reporter, Diane Solov of the Cleveland Plain Dealer, revealed them a couple days later.

Cosgrove, an international legend in cardio thoracic surgery, holder of 18 patents, author of a book and 400 journal articles, and surgeon of more than 18,000 cases, is dyslexic. He had been a C and D student in high school. Barely squeaked by on his entrance exams. And he had been accepted at the last medical school to which he had applied. Upon graduation, he had, largely through force of personality, worked his way into a residency at Massachusetts General, where he was ranked 13th of 13 residents. But like many other famous dyslexics, including renowned Hopkins pioneer Helen Taussig, M.D., Cosgrove overcompensated. Out of his shortcoming flowed genius. Robert Gross, M.D., had sensed that spark. Gross was the acclaimed surgeon at Boston Children's Hospital who was the first person in the world to operate on the cardiovascular system. He had helped train Cosgrove. Loop had also recognized that genius and cultivated the environment in which it would blossom.

Upward Trajectory

Loop and Cosgrove share much in common. Both built their surgical skills in the military. Cosgrove was awarded the Bronze Star for his work in Vietnam. Both are cardio thoracic surgeons. Both have international reputations. Both believe strongly in physician leadership. Both are strangers to cynicism. And both are deeply in love with the Cleveland Clinic.

At the end of the latest edition of the history of the Cleveland Clinic is a chart. It plots the growth of the institution from 1921 to 1994 based on the number of full-time staff at the end of each year. It reflects "predictable kinetics" not unlike "a huge bacterial culture" with a doubling of size every 15.6 years. In nature, such exponential growth usually plateaus as the limits of space and nutrients are encountered. But for the Cleveland Clinic, the chart reveals that there has been no plateau, only a steady upward trajectory.

This is the legacy that Cosgrove inherits along with the ever-forceful optimism of Loop, who has said, "Those who think our best years are behind us are looking in the wrong direction!" This is, after all, an organization that has just begun to build a million-square-foot heart center and has declared its intention to "end heart disease as we know it." It is launching the nation's first new medical school in more than two decades. Its approach to research and education are bound to be unconventional--"I want to build a system of discovery here," Loop once declared. He has suggested that "our greatest gift is hope. We will be a beacon of hope to all people in times of wellness and illness and through all the seasons of life."

As Cosgrove looks forward, what he sees is this: "As we act as a unit, the possibilities are endless." There is no cynicism in the Cleveland Clinic. It is a swelling pool of optimistic intent. The rising growth line in the chart took more than hope. It took self-confidence and will. And no small amount of ambition.

As I looked at the steep climb of the chart that plotted the clinic's growth, I couldn't help but think of a scene from the movie The Right Stuff, in which test pilot Chuck Yeager is inscribing a similar upward line of white contrail against blue as he tries to punch a hole in the sky. At 109,000 feet up, he finally edges the state-of-the-art aircraft beyond the envelope and into the lower limits of outer space. Then he drops back to earth. It took ego to be Chuck Yeager.

In his best-selling book by the same name, Tom Wolfe commented that "flying has a competitive structure that is as hotly contested as the world of show business. And the egos are just as big--in fact, in a way they're bigger. It's hard to top surgeons for sheer ego, but fighter pilots come close." In the end, it takes ego to drive a climbing record of growth and accomplishment, particularly when you're working at the edge of the envelope. Where would American health care be without optimism, ego, genius and ambition? Trapped inside the envelope, doomed never to capture a glimpse of the heavens beyond or their endless possibilities.

Originally published in Hospitals & Health Networks Online

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