Healthcare challenges are opportunities in disguise

Michael J. Dowling, President & CEO of a New York health system with 16 hospitals and the full continuum of care from acute to ambulatory, outpatients, long term and home care, looks at the useful lessons which Ireland might learn from this system. Maureen Browne reports from the joint HMI/RCPI seminar on “Leading and Managing in a High Performance Health System.”

All the healthcare challenges we see all around us are opportunities in disguise and leaders must believe challenges are opportunities, Limerick born Michael J. Dowling, President & CEO, of the North Shore-Long Island Jewish (LIJ) Health System, the largest integrated healthcare system in New York State, told the Conference.

Michael J. Dowling
Michael J. Dowling

He said that if hospital grouping went ahead in Ireland, it might be a step in the right direction and some of the things that he and his team had learned in building up their group in New York might be useful.

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The North Shore-LIJ Health System is the USA’s second largest, non-profit secular health system. It was founded in 1997, with the merger of the North Shore Health System and LIJ Medical Center, creating a healthcare network that now includes 16 world class hospitals, with over 5,600 beds and a total workforce of more than 42,000. It has a catchment of about seven million people in New York’s Long Island, Manhattan, Queens and Staten Island.

Its hospitals include specialty hospitals, a nationally distinguished children’s hospital, a renowned psychiatric facility, tertiary campuses, long term facilities, trauma centres, home health agencies, community hospitals, outpatient and ambulatory facilities and health and wellness programmes  in 400 locations.

The 16 hospitals which now have an integrated healthcare system were once completely independent, they didn’t like each other in fact they disliked each other.

“We have the full continuum of care from acute to ambulatory and outpatients to long term care to homecare”, he said.  “The distance between them is not far in miles but at 5 pm in New York you would be better off getting to Kennedy airport and coming to Dublin.

“We also have a huge educational enterprise, with1,400 residency fellows, 800 medical students and training programmes for our staff. We are going to open up a nursing school and we have one of the largest research facilities in the US.

“All of this is the result of multiple mergers. The 16 hospitals which now have an integrated healthcare system were once completely independent. They didn’t like each other in fact they disliked each other. In the mid ‘90s, the assumption was that these places could never come together and it was stupid and foolhardy to think they would. Today, they are completely and totally integrated and merged.  All have the same metrics and standards of quality, service and finance. The leadership of each of the facilities are people who know how to work together.  All of the back office functions are centralised.

When we began the work, some of the hospitals were in very poor financial condition; some were probably going to close.

“There is a single leadership across all the hospitals. I am CEO of each place. Legally, every hospital has to have a Board.  All our facilities have the same Board. There is a single administration and clinical leadership. Each hospital has an administration, a chief medical officer and a chief nurse and they are joined at the hip. Nothing happens without all three being informed. The clinical leadership cannot succeed without the administrative leadership being side by side and the same with the others. We have relationships with other hospitals around the place. There is one budget, one set of quality, service and financial metrics, the same in every place. It took years to develop this.

“When we began the work, some of the hospitals were in very poor financial condition; some were probably going to close.  Now they are all successful. It is all about bringing the service to the people in the community. We have moved services into the most appropriate place. We have closed beds and changed the space to ambulatory work. We have moved services, including tertiary cardiac services far out into a community hospital and turned it into a tertiary campus because that was where people lived.

“We are very focussed on having consistency in superior performance and the quality of our metrics is completely transparent.

“Once a month everybody, the administrators, clinicians and nurses share all data and talk about things that didn’t go well so that they can collectively figure out how this will not be repeated. The same happens with financial and service metrics.

We spend alot of time on employees who are the core of any organisation. We have to create a culture of continuous learning and continually invest in human capital. We have created the equivalent of an in-house university. Last year, well over 20,000 of our employees went through training. We have fellowships and high potential programmes for people we think have the ability to take leadership. Leaders promote the people who eventually take their jobs. We hire 125 people every week and I spend three hours with the new intake every Monday morning.

Mr. Dowling said that in healthcare, the more we collaborated, shared information and learned from each other the better would be our product.

“Despite other people’s view to the contrary, I think this is a very exciting period to be working in healthcare. It is a unique period. You can whine and complain about how bad things are going to be or you can say all of these challenges we see around us are opportunities in disguise.

“To me, leadership is extremely important. If you consider yourself a leader you must believe challenges are opportunities. If you believe in the concept of change, we have an unbelievable chance to change the way healthcare is delivered. If you believe in creating the future and if you believe in dispensing with tradition, this is a wonderful time, leaders embrace challenges and see beyond the current problems. They see what is out there in the future and visualise it. They can take current problems and turn them into successes. If you look long term you can see it with this perspective. I don’t think there is a better time to be in healthcare. Whether you are working in Ireland, the US, Sweden or any other country, the issues around healthcare are all the same – universal access to healthcare in appropriate settings and how to deal with the issue of producing better quality, better value and better results

There is also the challenge of the balance between the private sector and the government – how much should the government and the private sector be doing? There is the challenge of autonomy versus organised centralisation. How do you influence lifestyle and behaviours? These are the challenges with which everybody is dealing and nobody has the perfect answers.

“If you want to promote health and consider the long term goal is to promote health and not just treat illness then you have to look much broader than just at hospitals alone.

“We want to get away from a fee for service medicine and move into taking full bundle payment. We want to be in the business of promoting health as well as curing illness. We are moving into a whole new way of getting reimbursed. We are going to create our own insurance company where we will take the full risk. Competition is good and we want to get into the markets and offer our own products.

“If you move forward on groupings there is a great possibility to have competition between the groups and that is a very healthy thing.

“Leaders always have to get away from the way they work and figure out how to push the edge of the envelope and get to something very different, because staying in the same place does not get you to improvement. Transformation and initiation has to be part of the DNA of a good organisation.”

Mr. Dowling asked what should a hospital look like five years from now. Why should an Emergency Room be primarily attached to a hospital?  Why couldn’t hospitals work seven days a week?

“If I were paying a hospital, I would not pay them to do very little at the weekend or not to be open at the weekend.

“You have to build for long term sustainability. We just took a huge cut in our federal budget. Leadership is all about positive attitude. Outside influences affect us but do not control our future. Leadership is about creating risk, trying new things, not being a prisoner of tradition, sometimes asking for forgiveness rather than permission.”

Michael J. Dowling grew up in Limerick. He earned his undergraduate degree from University College Cork (UCC) and his Master’s Degree from Fordham University. He also has honorary doctorates from Hofstra University and Dowling College.