Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. We've talked about the collaborative efforts of competing health care institutions, like the Cleveland Clinic and University Hospitals before. And on today's episode, I want to revisit the partnership they've forged. That way we can dig deeper into what both institutions learned from the COVID-19 pandemic, and ultimately show how they're emerging from the crisis stronger together. To do that, I've invited Cleveland Clinic chief medical officer, Dr. Robert Wyllie, and University Hospitals' chief operating officer, Dr. Eric Beck. Bob, Eric, first question is how long have the two of you actually known each other. Robert Wyllie: We've known of each other for a long time. We started working together closely with the onset of the pandemic in March of 2020. Rae Woods: What was that actual meeting like, that first meeting? Robert Wyllie: Panicky. Because we were both looking at the video coming out of Asia. We were looking at hospitals in Wuhan and related cities that were overwhelmed. We were looming at bed capacity being superseded. And we also had a little idea of the infection rate, and how many people might be infected. So there was a real sense of urgency in our first discussion. Eric Beck: It was serendipitous that Bob and I had crossed paths probably 10 years ago and knew of each other, as Bob said. We were colleagues. But comforting to know that I at least had a beginning of a relationship with my colleague at the Cleveland Clinic. Like Bob said, I think there was a lot of uncertainty. And the opportunity for us to share that with each other immediately helped establish trust. Rae Woods: We've talked on Radio Advisory about this partnership between the Cleveland Clinic and University Hospitals before. Actually we had your CEOs on a few months ago. And they also kind of talked about the first time that they met. They had just happened to sit down for dinner, I think right before the pandemic actually hit, to explore this idea of working together. Even though your two organizations are pretty darn fierce competitors. We all of course know what happens next. COVID-19 totally turned the world upside down. And I think, frankly, caught our industry off guard. I want you to take me back to the very beginning of the pandemic. How was it that your two institutions realized that this problem was much bigger than any one hospital and you really needed to work together? Robert Wyllie: The modeling that was done suggested that we could have thousands and thousands of patients. So it became evident very early on that it superseded our total hospital capacity in Northern Ohio and in Cuyahoga County. And that each of us was going to have to try to manage, not only our own patients, but patients probably from other systems which were a little less sophisticated who needed to be transferred into Cleveland Clinic or University Hospital. Rae Woods: So the data was not looking good. And you realized this is not a Cleveland Clinic problem, not even a global problem, this is a problem that's going to be affecting our community specifically. Robert Wyllie: In a major way. And not only the hospitals, but we really hadn't done that much with public health. The county and the city departments of health kind of functioned independently from the major hospital systems. And so we had to make connections between congregate housing facilities. Because we knew older people were going to be especially affected by this virus. We knew that coming out of Asia. We knew the numbers were going to be significant. We didn't know how significant they might be. We knew we didn't have enough hospital beds. And we knew we were going to have to hook up with county health departments as well. So all of that I think was on our plate as Eric and I first started to talk. And there's something about two operations people talking, you immediately kind of sync up. Rae Woods: Yeah. And I think it's hard for people to kind of remember just how frenzied those first few weeks are, right? We're looking at a year and a half since that first onset of COVID-19. But I don't know that frenzied is even the right word to describe what needed to happen in those first few weeks. So when it came to the operations, Eric, I wonder if you can tell me where did you actually decide that you needed to work together? Eric Beck: During one of our first calls, Bob and I started talking about data. And as two of the largest providers in the Northern portion of the state, our combined data would allow us to really get a handle on how quickly things were developing, to give us the signal or the smoke before the fire, so to speak. We really hit it off, got our teams together, and within literally a matter of days, we had combined our testing data, our COVID testing data for both of our organizations, and really got quickly to work there. I think the other piece that was an early operational win was really aligning on common policy in which we said both of our organizations need to have uniform guidelines. Otherwise our front line caregivers are going to be confused, or not trust the advice because there are different recommendations coming out across the street. And I think those two were the real tip of the spear for me. Rae Woods: So basically you had this moment of there is no reason for our two organizations to reinvent the wheel, especially when the stakes are as high as a global crisis. So let's have combined data, combined recommendations for our clinicians themselves. What else were those kinds of essential pieces that when it came to fighting COVID-19, you said we are better off together than working separately? Robert Wyllie: So I think public messaging was very important as well. And we needed to combine public message, particularly in Cuyahoga County. If the Cleveland Clinic and University Hospital presented a different face to the public about what the recommendations were going to be, that would have been very confusing for the public. And so we needed to make sure that we were aligned in terms of the public messaging. Eric Beck: I think another element was we both adopted a test and treat in place, particular for congregate living and the post-acute facilities. And our ability to join forces there allowed us to contain a lot of patient volume in those facilities and prevent our hospitals from being overwhelmed. So I think that really resonated to me as another opportunity where competition was completely absent from the equation. It was really about how do we divide and conquer. And as we took that strategy to the state, Bob and I had to role model that same type of approach for other areas in the state that were perhaps a little earlier in the journey to having systems come together. Rae Woods: That's right, because if I can use a kind of a military analogy, there is a common enemy that will require a common approach to data and messaging and therapeutics and research, and eventually vaccinations, in order to make an impact. So what has that impact been on your region, and maybe on the state of Ohio more broadly? Robert Wyllie: The biggest advance within the state of Ohio has been forming zones, UH and Cleveland Clinic led zone one, which is approximately 50% of the population of the state of Ohio. It has about 450 of the 900 congregate facilities for the elderly population and the population of who's challenged with significant medical problems. And we knew, again, 450 facilities, how do we work together to manage all those facilities? Because any one of us could have been overwhelmed. So the idea is we also had to develop a load balancing system primarily between UH and the Cleveland Clinic, because we've got the greatest capacity. Eric Beck: I think the ability for both of our organizations to rapidly activate our incident command systems allowed us to have interoperable structures that we could then dock with each other and with other health systems in the zone, and ultimately across the state, to synchronize our operations, to do the load balancing that Bob referenced, and to coordinate our response in a way that really ensured uniformity in a time in which there were scarce resources and a fair amount of uncertainty regarding of all the guidance changes and modeling predictions. So I think that common structure allowed us to quickly synergize each other's efforts. Rae Woods: And let's be honest, in a way that really saved lives and protected a workforce that, I mean you said it yourself, Bob, could have very easily been overwhelmed. And thank goodness, because of this partnership, because of the efforts of competing organizations, that didn't happen. We never hit that kind of worst case scenario in the state of Ohio. Robert Wyllie: And both of us worked very hard to set up a kind of a triad. And the triad was a local hospital, even if it wasn't a Cleveland Clinic or University Hospital. It was a local health department. And then it was a skilled nursing facility or congregate living center to make sure that every local area had somebody that they could rely on and call. And then it was really our job. And we set up a system right away for an emergency line to call. If you're getting overwhelmed, call. And we would start load balancing the patients. We actually had an early experience with Elkton Federal Penitentiary in Columbiana County. They've got about 2,500 inmates, 300 employees. And within three or four weeks starting in April of 2020, about 1,200 of them became infected, quickly overwhelming the East Liverpool and Salem hospitals. And we set up our transfer line, transferred them into Akron. And then soon as Akron started to get full, we brought them up to Cleveland. Rae Woods: Now I know I started this conversation by asking about how you two came together, which was in a time of crisis. But the partnership, the broader partnership between Cleveland Clinic and University Hospitals is about more than just COVID-19, right? We talked about this on our last episode, how you're working together on shared services, broader research, bringing the best talent to the Cleveland area and so on. So when it comes to these kind of broader areas of partnership, I'm just curious at a high level, what strengths do you think each organization brings to the table? And how do you actually leverage those with somebody who is supposed to be your competitor? Robert Wyllie: Well, I'll give you an example of Northern Ohio Trauma System, which University and Metro and Cleveland Clinic are a part of. We joined several years ago, and we've actually improved trauma care within the city of Cleveland. And so University's got a level one trauma system at the main campus, both for adult and pediatric. We've got two level twos at Fairview and Hillcrest Hospital, which are the east and west side of the city. Metro has a level one. And we've got a level one in Akron. But if you aggregate all that together, if somebody has trauma, or an accident, or a gunshot, or anything else, we can get them to the nearest appropriate level trauma center. And we've developed common policies and common transfer arrangements for any patient who gets in trouble. Rae Woods: There are strengths in the literal assets that each of your organizations have with the goal of helping the community. Eric, what in your mind are some of the different strengths that each institution brings to the table? Eric Beck: The opportunity was to leverage our shared nonprofit community benefit focus. That we both really have the same mission at the end of the day. And if we can align on the same problem, the ability to move the needle there quickly is really unbelievable. Leveraging all those assets and expertise of the combined organization. So we think about a system of care not being just within a single health system, but really within a region or a geography. The ability to leverage data and to pool the talent around that data to me are probably enduring examples of how collaboration is not competitive, but in fact synergistic. Two plus two equals 10 in some cases. Rae Woods: Eric, you just perked my ears because you're talking about the benefits of acting as a system. Which if I'm honest, the conversations I have with healthcare organizations typically means within one organization, right? The ability of a provider to make progress because of its scale, not in spite of it, right? Acting as one unified organization. And that is difficult in its own right when you talk about making complex decisions, doing that centrally, rapidly, operating consistently, right? This is what individual organizations struggle with every single day. Rae Woods: And it strikes me that the success or failure of this partnership has a lot to do with that same element of systemness. The challenge is that you are not one organization. You are sort of a system of systems. So let's talk about what that means practically. What processes did you even have to put in place to take two competing organizations and actually come to consensus on what decisions you were going to make? Eric Beck: We had a wonderful battle rhythm of calls, daily calls, and email sharings, and analytical team outputs that allowed us to really role model the power of two large anchor institutions in the state coming together. And that wasn't an authority. That was merely a role modeling exercise. And so I think when two like-minded organizations can look at a common problem, align their assets and expertise intentionally around solving that problem, there's a followership that quickly developed. And I think that the entire region and the entire state benefited from those types of relationships being forged quickly, and then wrapping it with a cadence of daily calls to coordinate across institutions. Rae Woods: Was there ever difficulty coming to consensus? I have to imagine that there was a time when maybe it was the two of you, or some leader at UH said, "I think this is step one and step two," and someone at Cleveland Clinic said, "No, I think that's step three and step four." How did you deal with that? Robert Wyllie: I think it was surprisingly smooth, to be honest with you. Occasionally Eric and I would have individual phone calls apart from the other teams. Certainly if I had any major question, I called Eric, or if we're going to put out a policy, I shot it over to Eric for review by him but the UH team to make sure that it was in sync with what we're thinking about. What type of surgery are we going to continue to do? What are we going to do with employees? What PPE are employees going to wear? And it's going to be N95 mask, or regular surgical mask? And all those types of things to make sure that our employees felt safe with each other. But I think it was remarkably smooth. Rae Woods: But did you have a process in place to deal with disagreement? Robert Wyllie: That would just be a phone call between Eric and I. And those were usually quick, to be honest with you. I don't remember a long discussion that we had over policy. Eric Beck: I think we leveraged our internal experts. We would oftentimes tell them to all get on a Zoom together and kind of hash it out, put the best thinking, have the debate between three, four or five systems or teams. And I think that the output of those discussions were better for the richness of input. And there were a couple of times where perhaps Bob and I would agree to disagree, but it was nothing that we could never solve for, as Bob said, with a quick phone call. And I think that's the power of relationships and the power of cultivating those relationships, particularly when you're fighting a common cause. Robert Wyllie: When the troops know that you're going to have to agree and that you're going to have to come to consensus, and Eric and I project that for the people in operations, and I think that's what Eric's talking about in terms of getting the people who are working with us to say, look, get the groups together, come to some consensus. But they know that we have to have consensus and we're going to drive consensus. Rae Woods: And it strikes me that that leadership moment is probably even more important when you're talking about a cross system partnership because you do have to reflect the idea that you're practicing the collaboration that you are preaching. Eric Beck: Whenever we would agree to disagree about something, it was almost always something that was institutionally centric, and really didn't have a consequence for the broader public health or regional response. I can't think of a single example in which Bob and I and the rest of our teams didn't align on shared approaches to problems. Because we knew that there had to be a common path, or we would create confusion or risk the execution. Rae Woods: Which by the way, is a hallmark of systemness, right? Systemness isn't that even within one organization, every single practice, every single region, every single site of care needs to operate the exact same way. It's a matter of navigating where is variability welcome, and where is it going to hurt that common goal? But it strikes me that you're talking about a process that is very crisis driven. Daily meetings. Let's all get on a Zoom call. Let's hash this out on a phone call. And that's probably not sustainable in the long term. How has the operations of the partnership evolved since the beginning of the crisis? Robert Wyllie: I wouldn't say it's crisis driven, I would say it's problem driven, and the size of the problem. COVID came on very abruptly. And it meant that we had to achieve the systemness between the two hospital systems and delivery systems that you're talking about, the two largest to the state. But there were other ones that we've been thinking about for awhile, such as drug addiction, infant mortality. Those are beyond either one system. In fact, they're beyond both systems put together. Because there you have to get back into public health, the city of Cleveland, Cuyahoga County, you have to bring everything together. Robert Wyllie: So I think with the analytics that we've done, which are now operationally live in the state of Ohio with geospatial analytics, and that's probably the biggest accomplishment in terms of legacy that I think that we're leaving is a data system where we can see all kinds of trends in real-time, not only from another pandemic should it come, but also things like how many people are getting in trouble with new opioids coming in the country, and we don't know what their constituents, or with they're made of. We're taking a look at infant mortality, and why is it as high as it is in certain areas? So I think there's huge opportunity based on the geospatial analytics that we put together statewide. Rae Woods: You're talking about big systems coming together to tackle big, frankly, public health problems. And you just mentioned two of them. Are those the next areas of focus for this partnership? Robert Wyllie: Well, considering where Cleveland is in terms of its an infant mortality rate, one of the highest in any county in the United States, and the same is true for drug addiction. So I think these are major problems. Despite the fact of the healthcare power of these two huge systems, we still have challenges. And I think those are two things that I think both our CEOs have put on their radar in terms of trying to address. Eric Beck: Since the height of the pandemic, we've had enduring teams around a number of initiatives. And these are but two. I think the ability to carry that same approach that Bob referenced into more longstanding and enduring structural public health issues in our region is really what we're committed to. And we're a year into that now, and feel like we've got our footing underneath us. I do think data unlocks a lot of opportunity to collaborate. And that's a key puzzle piece that I think the pandemic unlocked for us. Rae Woods: I love this idea of switching from a crisis to enduring problems. But I do think that that is easier said than done, especially when, let's be honest, the entire workforce has been sprinting to try to get ahead of this very, very real crisis that we've been dealing with for the last year and a half. So as you think about carrying that momentum forward, dealing with infant mortality, dealing with the opioid crisis, what has been the essential features to keeping that momentum going and being able to tackle some of these enduring challenges? Robert Wyllie: Well, I think both of those that you just mentioned are related to health care directly. I mean, not only do we see the infants in our newborn units, which we both have, but we also in our emergency departments see a lot of opioid and drug addiction problems on a daily basis. We have people coming either overdosing or actually dying from overdose. So this is something which affects us every day. So I think those two are going to be relatively easy in terms of the enthusiasm of the workforce. We all went into medicine for a reason. And so I think that's part of the reason why people went in is to help. Rae Woods: How about the practicalities, right? Because you talked about things like sharing the actual load of making sure that no facility became overwhelmed with COVID. Can you give me kind of a practical example of how you would leverage this data, or the research that you do, or the workforce that you're partnering on in order to tackle some of these challenges? Eric Beck: One example is really around workforce, and really connecting with some communities inside of the city of Cleveland, in which we've put both of our data on the table, compared notes, and we've actually jointly branded initiatives inside of high schools, inside of local community organizations to help build pipeline strategies to solve our healthcare workforce shortage. That's a very tactical example of the power of our data. Eric Beck: I think the other piece that's really important is the power of inviting others into the partnership. So we've partnered with public health through the pandemic. And in many of these enduring structural issues, public health or city county officials are very important pieces of the team. The other component is understanding if there are other health systems or other healthcare organizations, whether it's federally qualified health centers or other providers that can help be part of the solution. Rae Woods: Yeah. That's really interesting to me because we're talking about the fact that these problems are bigger than any one organization. But let's be honest, they're also bigger than the combination of Cleveland Clinic and University Hospitals combined. So what is the process in place to add other institutions, competitors, or partners like these public health institutions, what's the process for adding them to your system of systems? Robert Wyllie: So I think we're both partnering with the Ohio Department of Health and the Ohio Hospital Association in terms of the analytics for the Ohio Hospital Association. But I was just on a call this morning with the Ohio Department of Health talking about what these cooperative arrangements are going to be coming out of COVID. And as we lose our focus on COVID, and have the opportunity to move into other public health measures, what does that look like? So I think we've done a lot. We've got the communication. And I think part of this we still have to figure out. But we don't want to lose all the forged relationships, and particularly the working relationships that we have with public health, if we're really going to address these problems. It's going to be a public private partnership between the large healthcare delivery systems, the cities and the counties, the city health departments, and the county health departments if we're going to make progress on these large issues. Eric Beck: It's been an inclusive approach from the beginning. So everyone is welcome. Any constituency or organization that can be part of the solution is welcome. And as Bob said, that's been at a state level, at a regional level, at a city level. And it cuts across not only healthcare providers and health systems, but anyone else. Community leaders, faith based organizations, officials all have been welcomed. And that's a guiding principle. Rae Woods: What about other kind of large healthcare institutions? I'm thinking health plans, tech companies, vendors, right? The kind of life sciences companies that also have a stake in massive challenges like COVID-19, like infant mortality, like the opioid crisis. How do you bring them into the fold. Robert Wyllie: Both the Cleveland Clinic and the University, both of us are working with the large Medicaid providers within the state of Ohio. There are six of them. CareSource is probably the name of the largest one in the Cleveland area. But we're working directly with the executives within those organizations to see how we're going to provide, not only COVID care, but ongoing care after that. A lot of these are people who have significant challenges that need to be addressed. It can be transportation, it can be poverty, being home bound. And how do we get our care delivery systems to work within those confines, and what does that look like? Eric Beck: I would say both before the pandemic, accelerated by the pandemic, and after the pandemic, we have teams that are collaborating on innovative solutions to both COVID and non-COVID challenges in healthcare. And whether those are startup companies, whether those are payers that are willing to pilot new approaches, there's an ecosystem that that was present before the pandemic that was collaborative. But I think the pandemic exercise really allowed us to see that ecosystem come to life in tackling some of the more contemporary challenges. Rae Woods: Well, I am deeply impressed with your ability to kind of reach across the aisle and develop a very, very robust partnership. That's not just at the kind of executive level, but really has an operational backbone as well. But I don't want to pretend that any process or partnership is perfect. What stumbling blocks did you hit along the way that you want to help our listeners avoid? Robert Wyllie: I'm speaking, honestly, from my point of view, with the ease of communication that we have, even if we disagreed on some policies or the exact wording of the policy, the intent was always the same. We're also both trying to improve the healthcare of individuals who live within Northeast Ohio. So our goal is aligned with each other. I think the fact that we're competitors in cardiac disease and in other individual service lines, of course, we're trying to get better and we're both trying to innovate. On the other hand, I think having a major competitor sitting right next to each other in the city of Cleveland probably makes both of us a little bit better. Pushes both of us to continue to innovate, to continue to strive. Robert Wyllie: So I actually don't see it as a negative when we're "competing" with each other. I mean, we're competing on outcomes, trying to get better. We learn from each other. There's a large Case Cancer Organization, which includes both the Cleveland Clinic and University Hospitals centered at Case Western University. That organization has been around for, Eric, maybe a decade or so, where we combined research activities. We do combined research all the time. Which greatly probably facilitates our ability to maintain funding and to provide outcomes in terms of getting to answers much quicker. Rae Woods: So you don't feel like this partnership has prevented you from being able to rightfully compete, right? Which is important because very, very like-minded organizations like yourselves make for a good partnership. But it also means you're kind of trying to go down the same path, maybe even acquiring the same institutions in the market, or looking at similar growth opportunities. And I can imagine that that can be difficult in some moments. Or maybe it hasn't been a problem. Eric Beck: I think at the end of the day, competition is ultimately neither good nor bad. It's really the character of the organizations and how they choose to behave. And I would say that Bob and I are part of rival organizations, but there's a mutual respect and admiration for each other's organizations and each other as individuals that I think allows us to not focus on the competitive dimension, but understand how neither of us has to lose for each of us to win. And in fact, we can win together when we come together around those things that are areas of coopertition. Rae Woods: Coopertition, like the two words, cooperation and competition together? Has that become a rallying cry? Robert Wyllie: I will say that healthcare in general has a little different attitude towards competition. And so that if somebody does something better and their outcomes are significantly different or better than somebody else, all of us will pick up the phone and say, "What are you doing? How did you do that? How did you achieve those results?" And every health healthcare system that I've ever called has been quite willing to say, this is what we're doing. Rae Woods: Yeah. There's no secret sauce in healthcare. We want to share the secret sauce with the masses. Robert Wyllie: It's about people, and it's about making people better. So the type of people who go into medicine in general are very quick to share whatever advances they have. Rae Woods: Like I said, I'm really proud of what the two of you have built. And I think when you look back at the processes, the initiatives, the results that you've been able to get over the last 18 months, and as you're looking towards the future, you've probably had really proud moments yourself. So I want you to look back for me. What's the best thing that this partnership has produced in your mind? Eric Beck: I think there's a fondness for the teams that have come together that is continuing today. And those relationships really emerged and flourished during the pandemic. But the ability to engage in an ongoing partnership I think is really what has me most proud. Robert Wyllie: And I'll certainly second that from Eric, but will add the geospatial analytics platform that we have developed within Case Western University, University Hospitals, and Cleveland Clinic. And then taken that statewide to give us a data system which is unique to the state of Ohio in terms of early recognition of problems or trends. And I think that's going to serve us well moving into the future. Rae Woods: Which is exactly where I want to go next. If both of you just looked back, now I want to ask you to look forward. I want you to roll the tape forward five years into the future. What do you hope the partnership between your institution looks like in five years, and what are you going to do to make sure that you hit that reality? Eric Beck: I'd love for us to make a dent in a couple of these enduring public health challenges in our ecosystem. And we're making great strides on that. But to see the results of continued persistent collaboration in that vein in five years could really mean the difference for our community. I'm personally going to commit to a regular coffee with Bob, whether that's by video or in person. Because our relationship is really better for the time we've had a chance to spend together over the past couple of years. And I think our organizations are better because of that. Robert Wyllie: I'll agree. We want to maintain the structure and the communication that we have, not only with each other, but with the county and the city boards of health, as well as the nursing facilities that are many of our elderly disabled people live in in the state of Ohio so that we can continue to leverage those relationships and improve the health of Northern Ohio. Rae Woods: Well, Bob, Eric, I want to thank you so much for coming on Radio Advisory. Before I let you go, I do have one final question to ask you. And it's sort of a moment for you to speak to our listeners directly and to give them an action item that they can take back to their region, to their institution, and maybe even adopt some of these partnership mentalities themselves. What's the one thing that you want our listeners to do as a result of listening to this conversation? Eric Beck: I think in healthcare, we all have peer groups. And oftentimes they're from larger societies or organizations. But I would encourage everyone listening to find a few people that you don't know in competing or other community-based organizations, and reach out and develop a relationship. Find a shared opportunity to collaborate and see where it goes. Because we certainly unlocked a lot of potential in our organizations through the pandemic. Robert Wyllie: And I will say this isn't over yet. Go out and get immunized if you haven't. And secondly, I would say remain engaged. Not only interested in what's happening, but remain engaged in public health, remain thoughtful and knowledgeable of what information is out there and aware. Rae Woods: Thank you both so much for coming on Radio Advisory. Robert Wyllie: Thank you. Eric Beck: Thanks. Rae Woods: Finding common ground with competitors is still uncharted territory for most of the healthcare industry. And to be honest, it will require leaders to suspend their own ego and explore relationships that were previously undefined. But as we learned from the Cleveland Clinic and University Hospitals, this coopertition is the single best way to support the broader community. And it's a model that we want you to emulate. So remember, as always, we're here to help.