Creating a Patient-Centered Healthcare System with Tommaso Falcone, MD

Podcast Transcript

Brian Bolwell, MD:Welcome to Beyond Leadership: At the Intersection of Leadership and Everything else. Hi, everyone. Welcome to today's episode of Beyond Leadership. I am your host, Dr. Brian Bolwell, director of Physician and Leadership Development of Jack, Joseph and Morton Mandel Global Learning and Leadership Institute.

Today, I'm thrilled to have a good friend of mine, Dr. Tommaso Falcone, join us for today's conversation. Tommaso is currently chief of staff, chief academic officer and medical director at Cleveland Clinic London. Tommaso, welcome.

Tommaso Falcone, MD:Thank you very much. Nice to see you virtually, Brian.

Brian Bolwell, MD:It's good to have you. For our listeners, you joined the clinic a while ago and you actually relocated from Canada.

Tommaso Falcone, MD:Yeah.

Brian Bolwell, MD:I think your first job was actually to lead the Women's Health Institute. Is that correct?

Tommaso Falcone, MD:No. My first job was to lead the Reproductive Endocrinology/Infertility. I trained at McGill University and I had finished my fellowship, McGill University and I was there for few years. Then one of my fellows came to Cleveland Clinic in Cleveland as a fellow, and he mentioned who was the chairman then, it was Jerry Belinson and who was looking for the head of reproductive oncology. He said, "We have someone who's doing this minimally invasive surgery," because it had started at that time in the early '90s. He called me, Jerry called me, and says, "We'd like to interview you, because we're looking for a head of REI and start a minimally invasive program." I said, "Oh great, thank you." He said, "Send me your CV." I hung up, and I didn't bother.

I went to my wife and my wife said, "Our family is here," Her mother, parents, everybody, which are still there. About two weeks or so later, Jerry Belinson calls me up again and he says, "I didn't receive your CV." I said, "Oh gee, I thought I sent it." Now I felt very guilty for this, and so then I did send my CV, and then I told my wife, "I'm just going to go and it's just to talk, and there's nothing else." Then when I, of course, arrived here, I was really impressed with the culture, and this was 1995. Very different from a university, which what I was used to, McGill, where basically we were, and at that time anyway, where research and education was first, and we also did patient care.

What I liked about the Cleveland Clinic was we did patient care first. We also did research and education. Then I came here as the head of Reproductive and Oncology and Fertility, and then for about four, five years later, Jerry Belinson stepped down and I was fortunate enough to be named as chair of the Department of Ob/Gyn, because at that time, remember we had divisions of medicine and surgery and everything was in medicine, surgery as traditional. I was appointed in 2001 as the chair of Ob/Gyn and we were about 20 people at the time, 20 docs. Then when Toby Cosgrove came in and we created, as you know, Brian, these institutes with really the vision that he had, which was to say, "Look, cardiologists and cardiac surgeons have more in common than chief of medicine, which was a pulmonary physician or something.

So we created the institutes, then I became institute chair, and then so from 2001, 2018, I led the Ob/Gyn and Women's Health. Then in 2018, after 17 years, I figured it was time for someone else to do of the job. I had expanded, we started as a main campus, just like cancer, main campus group. Then we grew to Fairview and Hillcrest and then Medina and Akron, everything, so it was really exciting. I really enjoyed it. I loved my job and I would not have given it up unless I thought that it was time for someone else to do it. I thought I left at a good time. That's the best time to leave, when you're at the top rather than at the bottom. Of course, I didn't foresee COVID, but the reality though is, is I felt that I had done my duty and another opportunity came up, and that's the reason why I went to London and been there for the last three years.

Brian Bolwell, MD:So Tommaso, before we get to London, which I'm very curious about and I know our listeners will be interested in, a couple of questions about your tenure as chair of the Women's Health Institute. One of the challenges I know you had was, as you mentioned, we had obstetrical care in a variety of regional hospitals and you actually had to stop it in at least one, if not more, of those regional hospitals, which became a rather emotionally charged event and probably required a fair amount of leadership skill. Can you share with us how that occurred and what you learned and what you tried to do to make it all okay?

Tommaso Falcone, MD:Right, and I think that's a very important question as to the distribution of services within a health system. So that's the overarching question that you had, and obstetrics is the most sensitive one. We did the same for cancer. We didn't have cancer gynecologists at Marymount, for example. We didn't have cancer gynecologists at Medina, but we have a great cancer gynecology program. But obstetrics is one that's closest to let us say to the heart of the community, but at the same time we had to balance what can be seen, arguably, as modern obstetrics. Modern obstetrics, in the old days when I trained each individual obstetrician ran in at two o'clock in the morning and did their delivery and was late, like the baby was crowning, or they had a small group of three and they would be exhausted all the time.

Tommaso Falcone, MD:We got to the point where, and especially with this younger generation, which was very much true, and they said, "Look, this is not sustainable. We cannot work this way for patient safety." But then patient safety became the issue at multiple levels. The first level was that the doctor said, "I cannot physically come in at two o'clock in the morning, do my duty to this patient, and then at 8:00 AM go and operate." Then we said, "Okay, then we need a critical mass," and the critical mass wasn't there in these community hospitals. Secondly, they all said, "We want in modern medicine, obstetrics, you need to provide us with a high risk obstetrician." So then the high risk obstetricians went to five, six hospitals, again, not sustainable.

Then finally the studies have shown that it takes a critical mass of obstetrics, of deliveries, for someone, nurses, allied health professionals to maintain their skill set. Obstetric is mostly, it's 80% nice stuff going on, really community, really the husband and the wife, the husband and the woman, or the woman and the woman, the couple do all the work. We just stand there and make sure things go, so that only 10%, 15% of the time do we actually intervene. Anyway, we couldn't sustain that, and for this reason, we had to make the tough... and I really mean tough decisions, to say, "I cannot provide this." For this reason we started with different hospitals, like Euclid in fact was the first one that asked for help.

Then we had Marymount and then Medina. I was involved at all of these, including Huron Hospital. We said, "I cannot provide these services. I cannot recruit doctors of the modern era that are willing to work in this way of the old days." Because of the quality and safety issues and not that we had... there were bad outcomes, but we felt that we're... as we were moving into a new era, and that's how we came out. It was always patient safety, always quality and safety first, and that's how we made those decisions. But you're right, I mean, I had to stand in front of the community and explain that we were not going to continue this, and people really didn't like us for that. I think with time, maybe all wounds are healed, but it was a tough decision, as in many other decisions that people make about providing all sorts of subspecialty care.

Brian Bolwell, MD:Well, but one of the keys I think is when we talk about change management, starting with why is always a pretty good idea, and so, as you articulated, starting with quality and sustainability and just dealing with the realities of the workforce, I mean, it was all honest, it was all the truth. But that's always a pretty good place to start if you're going to make some sort of substantive change to whatever you're doing.

The other thing I thought I'd raise is, so you and I were the two vice chiefs of staff for quite a while under Dr. Cosgrove's leadership and with the chief of staff being Johan. I think we both learned a lot about leadership, as well as the organization. Can you share with us what that was like?

Tommaso Falcone, MD:Right, so I was, like you were Brian, we were both... We were elected first as members of the Board of Governors, medical executive. I served from 2006 to 2010, and then afterwards, because we were vice chairs, they were originally called associate chiefs of staff, but Johan felt that vice chairs was the more appropriate. We were still on the Board of Governors from 2011 to 2013, so we were there for quite a few years. Then of course we served on the executive team as well from 2007, 2010. During those years, we saw tremendous change. We've moved rapidly away from what was the traditional way of looking at medicine, which is these silos of medicine and surgery and all that, and so it took a lot of communication skills to explain to the group of docs that we had that we're going to change the entire paradigm of the way we're going to arrange an organizational chart.

People's identity, the identity of someone, I am a medical person, and now I'm reporting to a surgeon, that took a lot of communication to them and a lot of communication of a vision that this is going to be better. This is better for patient care. This is better for research and education. Communication on that vision took a lot. When we were both on those medical executive Board of Governor as the executive team, our responsibility was to take the vision that was being given, and the other way around is to take what our constituency, which were our doctors, that's who we represented, and bring that back to the medical executives, to the Board of Governors, to the executive team. It was not a one-way street and we were right in the middle, we took what they gave us and we went to the docs, and the doctors, our constituency said, "I feel uncomfortable with this. I feel stress with this. I feel anxiety that I have came, I have moved from California, and now what you're doing is changing all this."

That was really our responsibility to bring to the group, and I think that we did a pretty good job of representing them, because of these anxieties. I think to this day, I feel that that is the primary responsibility of people that sit in both worlds on these executives and in the clinical world. I think that we certainly got into some, let us say, not heated discussion, but quite close, as to the way we came on an issue. But I think that, in retrospect, I felt it was my responsibility, and I think that I would do the same thing again, but that's the way it was in those years.

Then of course, when these things move on, people are reassessing everything, and they may forget as we went from divisions, surgery and medicine into institutes. I mean, institutes pose their own issues, but people forget that we tried to do it for purposes of better integration of clinical services for patient care, but also research and education. What we had, I'm sure that in cancer, you had more common with cancer surgeons than you did with someone who was in charge of inflammatory bowel disease and who was chair of medicine or something of that nature. I think those were... the time we spent, I think it was time for me and I think perhaps you too, Brian, that we did our duty, and we spent a good number of years on those executive teams. I think it was... I'm very happy, that I think that there's a group that have come in to take over the responsibility.

Brian Bolwell, MD:They were fascinating times back then. I think that Dr. Cosgrove sometimes doesn't get the credit he deserves for some of the changes he made. I think that we were one of the first organizations to really focus substantially on patient experience. Just kind of rolling that out and keeping the physicians comfortable with what that was all about, that was another lift and that was something that I think we executed well, again, starting with why. It certainly makes sense that we want our patients to feel good about being a patient here at the clinic and to have the best experience they possibly can.

Toby rolled out a lot of transparency, with dashboards and a lot of modern business intelligence tools, which at the time was pretty novel. The other thing that I've talked about a lot on this podcast is that early on, he was very into executive coaching and he gave all of us a coach and we all had a 360. That was important for me because I learned an awful lot about my leadership flaws and my mistakes and my opportunities to improve. I know you and I talked about that a fair amount and I will always be very appreciative for that, because that was really important for me to learn.

Tommaso Falcone, MD:Yeah. I agree. I think that especially when I think of surgeons, we always think of that our main redeeming feature is empathy. In fact, if you ask patients, it's not. They say, "I've come to see you because you're skilled. Your empathy, I'm not so sure." But for doctors, or surgeons as well, we all think that empathy is our main redeeming feature and that we are very sensitive to patients. Of course, when you look at the patient experience scores, which were a revelation to, I think, a lot of people, as well as these 360s about how we feel we are leaders. In fact, in my successors in the Women's Health Institute, I always tell them, I said, "Look, when you do these 360s, you have to take this seriously, but you may feel hurt."

I said, "You need to be ready for this." I said, "You'll see things that you cannot believe that people think of you, even though you spend a lot of time saying, 'I don't understand. I'm a really sensitive person. I think I listen to people. Then you read the survey and then you're insensitive." I couldn't believe it, but I would tell the others that are in this leadership role, I said, "Just be ready for it, because you really feel you went into medicine because we think we're have a lot of empathy. We listen, and it turns out that maybe we're not that good at it, and certainly as a leader. So go in there with these 360s and I learned a lot and I improved."

Of course, as a lot of people, I felt a little bit depressed afterwards. I said, "I don't understand. I feel I work hard for my group. I mean, it's a priority for me." But then once you get over that part, you realize that, yeah, maybe there is truth to this and I can improve both with the patient experience as well as in our leadership role with our group.

Brian Bolwell, MD:Yeah, for me, I was hurt a lot. It was actually almost palpably painful, but I think it was very necessary and it certainly stimulated my motivation to learn more about leadership and to try to change and get better. Clearly, I was doing some things that were not resonating with a lot of people and I needed to evolve. Again, I'll always be very appreciative for that because it really started me on this journey to read a lot about leadership and to talk to people about it and now to try to educate about it. And it was hard to talk about it in that era.

Tommaso Falcone, MD:So the era, well, there are a few things I do think that you said, and I just wanted to bring it up again. Definitely Dr. Cosgrove was a visionary. There's no question that he... There was a question of patient experience, this concept of institutes, but also integration. He really did see the Cleveland Clinic health system as an integrated system, that it was our job, our responsibility to integrate and was not easy. The culture, what people forget, I would go to Hillcrest Hospital and they say, they would say to me, "Cleveland Clinic is not coming in here." I said, "But, you are Cleveland Clinic now. The hospital is part of the Cleveland Clinic system." So even though their paycheck said Cleveland Clinic, they did not see themselves as Cleveland Clinic for quite a while.

I mean, now is completely different because like 15 years later, but I assure you it was not like we were saying that this is it. The same thing goes with Fairview. They had their own hospital, their own doctors, that were employed by these hospitals. Toby said, "You need to integrate it." But it was not as easy is as, "Here it is, please do that." The culture was different. Well, the main campus culture and those cultures were very different and they did not see us as a unit for quite a while, and it took a long time. Now people maybe don't see it that way, but we had many, many, many meetings where I would go to and say, "Look, we're all one Cleveland Clinic," and then the docs that were there already.

When I speak to my colleagues in Florida, what they're undergoing now is what we did 15 years ago in integrating that. I mean, so these labor and delivery, et cetera, that we had, like cancer centers, these people did not see us in that and it took a lot of time for us to integrate. The other vision, of course, was the electronic medical record, which was another painful journey for a lot of people. Now, people, I don't even know that because it's now I'm revisiting it again in London, where we're introducing Epic and these guys say, "This is insane. Just give me a pen, a piece of paper and I can do this much quicker than we did." It's true. When we introduced Epic, it was sort of low key and slowly built up. Now we're just throwing 2021, 2022 Epic there and it's painful.

A lot of these journeys that people take for granted, it's took a long time. Every one of them, Epic, integration of hospitals, consolidation of services, it took a decade of communication. It took a decade of presenting a vision, which of course the CEO brought to us and it was our responsibility. I think that the main thing at the time, and I don't know how people would do it in the modern era when they're integrating people, but at that time, when I went personally, I felt I needed to make sure that they looked at me and they said, "I can trust this person. He's going to be honest. He's going to be fair. I understand it's tough, but I am not suspicious of his motives. He does really want to integrate." Not all people agree, but I mean, I had to sell the vision, but first I had to sell the concept that I was there to represent them as much as the organization.

Brian Bolwell, MD:For our listeners, there's a lot of really important points that Tommaso just talked about, and just to follow up on a couple. I think an awful lot of healthcare organizations are dealing with integration right now, and as you said, it's not easy. In fact, it's very, very difficult. We did a lot of things. I mean, one of the things I remember we did early on was make supply chain the same for all of our regional hospitals, because at the time each hospital purchased items independently. There was not a unified approach. Secondly, one of the reasons that we were such an early adapter of the electronic medical record was to assist with integration, because it became a unifying tool clinically for all of the clinicians, the docs and the nurses, at all of our regional hospitals and even our family health centers that are outpatient facilities.

The other thing I'd like to, again, reiterate is what you said you personally did. I think that number one, face-to-face interactions are always the best way to go about anything you do, really, with any sort of relationship, but to try to generate trust and to be honest and know that you're going to give somebody a straight answer. They may not like it, they may not agree with it, but at least you'll, number one, tell them the truth and number two, listen to them is so important. We talk about trust all the time on this podcast, but, but boy, I just think it's a crucial ingredient to leadership.

Tommaso Falcone, MD:Yeah, I agree. I think that those characteristics and your leadership skills that you need change with where you are in your, first, career and also change with where the mission is, like integration versus stabilization. Or right now in London, I'm recruiting and we've recruited a lot of doctors. They come in, and I'm offering them a completely different model. The private practice in London is a solo practice. It is Hillcrest or Fairview, America 25 years ago. I am an independent person. Like my team, I don't have a really a team, but I have people that cover me when I'm away on vacation, but this is my patients, here's my phone number, and that's it. They do not have teams in private practice.

They do have teams within the trusts, which is the national health system, but in the private practice, none. So when they came to us, they said, "You're going to part of a team. You're not going to be a solo practitioner. This is not our model." Employment is really just an end to the concept of teamwork and they have to come. In fact, they all have busy practices, so they're taking risks. We certainly do not pay them more than they're making now, so they're not coming for the money. They're coming for a culture where we tell them we're going to work as a team, so we have a team for cardiac and a team for foregut, et cetera. There are different skill sets in leadership that you need, and for mine has sort of switch from my role when I was a Women's Health Institute chair.

My real role, other than to obviously maintain patients first, quality and safety, access to care, all the important metrics that we have. But honestly, my main role was to create opportunity for the next generation, because there comes a time, you say, okay, well, I'm not going to be... when I had done it for 15 years said, said there's no way I'm going to do this for another 15 years because someone else has to do it, give others opportunity. But during that time, you have to create opportunity for the next group of leaders. If you were just saying, they'll figure it out when I'm gone, that you're not leaving your institution at all. Someone said to me when I came back, had coffee with them after I was gone for a couple years, and they said... They sat with me and they said, "I can't believe you built this institute when there were 20 people, there were 160 when you left. We thought for sure you had so much influence over so many years that when you left things were becoming unstable, and they were not."

I said, "Well, that's the best compliment that you can give me. I'm not there to say, "Without Tommaso, this doesn't work." I want to say, I want you to say, 'Even without him, we're doing fine.'" Because my responsibility was to create opportunities, to look at the next group so they can continue, so was my responsibility when I was here. Now, my responsibility in London obviously is back almost 15 years is to build a group of doctors which will adapt to our culture, that see our culture as the main one. That's again communicating vision, communicating what we try to do when we were closing obstetric units, for example, and you have to do it with... that you have to say that we are fair, we're transparent, like Cleveland Clinic's transparent. When you join us, it's all of a sudden, you're not going to say, Here, I've taken this out of the drawer, and by the way... "

There's no point to it. It's not in their benefit or our benefit. The other thing which I'd learned when I went to London, which we have to always remind, is humility. The reality is, is that if I would've said, "This is the American way, and we're going to do it the American way," we would've failed immediately. What we said was this is part of our Cleveland Clinic culture, and the Brits have their own very proud culture. I said, "We're going to put them together and then we're going to come up with this." Leadership skills that you acquire for different parts of where you are in your institute or department or group is different from where the mission is at the time.

Brian Bolwell, MD:Yeah, I think that's another really good point, and certainly to your great credit, Tommaso, you groomed our current chief of staff, Beri Ridgeway, and that's a high compliment to you. What is Cleveland Clinic London? What is the status? I know there were challenges with COVID all over the world. Certainly it affected the UK. Why did you decide to go there and what's going on now? I'll just kind of give you an opportunity to educate us about what it is, why it is, and what's going on.

Tommaso Falcone, MD:Well, it's always a combination of events. When I came to Cleveland, it was like my fellow happened to come. If he would've gone to Mayo Clinic, probably would still be in Montreal. There came a time within the Women's Health Institute, like I said, I had done it for 17 years, I had successors. In fact, remember my successor in Women's Health Institute was Beri Ridgeway. I knew that we had good people, and I felt it was time to hand it over, but I had no intention of leaving unless I had something interesting. This opportunity came up in London where my job as chief of staff was to really build clinical programs. What was obviously unique is that I had to build... Build meant choose leaders, because I was in building our cardiac program, but I chose the leaders who built it. It was interesting because I could do it not only in Ob/Gyn, which of course is a minor concept there, but all of them.

When I talked to the current CEO, Brian Donley, and I said, "My role is to... "He said, "We want to build all the clinical programs by choosing the leaders and then mentoring them in our culture." Simultaneously, I was also responsible for building the infrastructure for research and education. We have fellows, we have a research footprint. I learned many things. There is no hospital IRB, like ours. It's a state run one, so every time I said, "Well, we have to have our own IRB," they said, "It's not the way it works. There's a state run one, you have to apply." Which we were the first in the United Kingdom to apply, to do research in a private hospital. No private hospital has ever done research there. It's all done in the trust and the universities, and so we have to go through this.

When this opportunity came up to build all these, this, and I felt that it was time to hand it over to someone else, and of course at the same time, our children at that time were either in college or finished university and so therefore we were empty nesters, although that's a loose term. The kids never or really go away somehow, they bounce back, but at least we didn't have to hire babysitters or people to take care of them. So with my wife and I, we decided this was good. I also felt that... I did it because I really wanted a job. You had a CEO that was visionary as well, which was Brian Donley, and I said, "Okay, I want to do this," and our kids are gone.

At the same time, I also felt, but wasn't really a critical reason, but I think it's also important for a previous chair to get out of the way of the new chair, because certainly, and maybe, Brian, you can give your personal experience because you're just around the corner, but the tendency would be to run to me because that's what they did for 17 years. They said, "Hey, the sky's falling." Well, I said, "Well, the sky's falling. It's been falling forever, and let's deal with it." But it really should be the next person, and I did not want to interfere. The longer you've been somewhere in a leadership role, the more difficult it is.

When I moved to London, believe me, I still got a lot of emails, but it was clear that I cannot manage that, and I felt that, so... But the reason is because I really wanted this opportunity. Remember Cleveland Clinic London is a high acuity surgical interventional hospital. So basically it's the main campus without Medicare or Medicaid, because the Medicare Medicaid, which is the trust that's handled. So it's self-pay, private practice, tremendous international. Unique feature is we want to do the tough cases, which is part of our culture, and so therefore we want the difficult cases.

We will build. Our footprint is started with the four services, cardiac, neuro, orthopedics, and digestive disease. There are different phases. We have big surgical oncology, but not medical oncology, which is the next phase. But the point of it is that's what drew me there is, is that that footprint is going to be extraordinary, extraordinary infrastructure, great team. Then finally, get out of the way of the next person. Did you find that you had difficulties since you stayed after you moved on from chair, that that was a challenge?

Brian Bolwell, MD:To some degree, but similar to you, Tom, I left for a couple reasons. I did want to go out on top as you articulated, and I thought the cancer center was in very, very good shape. I had a unique opportunity to come over here and do something that I'm very, very interested. I'm very interested in learning about leadership and studying it and hopefully to try to educate a variety of people throughout the organization and beyond about it. Then there're the whole concept of term limits. I think that there are people in academic medicine who hold under their jobs for decades and that never made a whole lot of sense to me. One of my mentors, a guy named Joe Simone, has a pretty famous article about academic healthcare systems, and one of the things he said is, "If you're a leader, you're probably going to accomplish 90% of whatever you were destined to accomplish in the first 10 years and trying to get the last remaining 10% probably isn't worth it," and that kind of resonated with me.

But actually no, I've really tried to let the people who are currently running the cancer center run the cancer center and I'm of course available if they want to ask me a question, but it's usually pretty technical. It's usually about some sort of maybe legal issue that came up a couple years ago as opposed to kind of day-to-day operations. The UK endeavor sounds fascinating, and yeah, I know that recently you opened up your outpatient facility and I heard that went well. Can you tell us about that?

Tommaso Falcone, MD:Originally we were going to open the outpatient facility and hospital simultaneously, and that was the original intention. What happened when COVID hit and delayed the hospital for a good amount of time last year in 2020 specifically, I mean, there was no one in the hospital working. Everything ground to a complete halt, and we made a decision last year, said, "What are we going to do to revise the hospital?" Again, the opening, it was revised several times. But we did say at the time, we had a long discussion about, should we separate the opening of the clinics from the hospital? Now, that's very difficult, given the fact that we are a high acuity surgical hospital, interventional hospital, so what are we recruiting that can't go into the hospital?

That did, and it still does create problems of transition. But then we said, "Look, although we will have challenges, the reality is, is that we can learn. Rather than learning in a hospital setting where we have to run an ICU, which is 20% of the beds because of the cardiac and neuro patients, let's open the clinic so that we can learn from how a private practice group will run with our culture, but at the same time some of the UK doctors. So we said, "Okay, let's open this before the hospital." We uncoupled the opening of the clinics from the opening of the hospital, because we said that this is what we would do. In fact, we set a date for September 14, more than a year ago.

With all delays and everything, we actually met it and so we did open and then we had 140 doctors coming in. Remember the docs, most of our docs are only part-time with us. They're employed, but they're part-time, because actually they work in the trusts the rest of the time. So we have this and culturally, we learned a lot of things, like for me as a gynecologist, I always have three rooms when I see patients, so you go in and the whole thing. Or an orthopedic surgeon would have like, I don't know, 10 rooms or something. I exaggerate, but there one consultant gets one room. They walk into room and they basically stay there, and the nurse brings in the patients one after the other.

In fact, even in the operating room, its one surgeon gets one room, that's it, one anesthetist, one anesthesiologist, one room with him. So it's a very different world. But so we open and we had a big team come from Cleveland Clinic here there for introduction of Epic, and we learned a lot of what we did well, what we did okay, and what we did completely wrong. A lot of it was a surprise, because, again, you have to understand, and even if you understand something intellectually, when it comes down to the emotional part and they're so used to, for example, medical secretaries are a huge component of what a British doctor does. Their medical secretary is the interface, it's a patient facilitator.

You see, for us, we moved away from that and you remember it afterwards that when I started like you, 25 years ago, our secretaries did everything. Patient called, book this, book that, call this. They were really patient facilitators. They weren't typists. With time, as we decoupled all this, and we had people, this contact center or et cetera, the medical secretaries went away but slowly, so then we got Epic and Dragon and all these things. So these guys, we took them from what we were in the year 1999 to 2021 in one week, and that was not well. Because they were so used to the secretaries, they would just come out in the whole thing. We learned a lot, but it went very well and in fact, we've now seen, the last three months, over 10,000 patients and therefore patient visits, and it's amazing.

It's fascinating how private practice in London, imaging is a big part, like it takes a long time to get an MR of your shoulder, if you go to the trust. You can get it tomorrow, within private practice. We learned a lot. We did this and when we learned about payers, we learned about how to run clinical practices. We learned very importantly to listen even more to the docs and say, "Look, I'm willing to do it your way, but just remember you have caused me pain, because I'm used to picking up one person. Where's Joe? Joe is the guy I call. He's my assistant and Joe takes care of scheduling and this and that," and there is no more Joe. There is a contact center, et cetera, et cetera.

It worked out well, 24 Portland Place is the first of the outpatient clinics. The hospital will also have outpatient clinics, but more the high acuity surgeons, like you don't need a cardiac surgeon seeing patients on an outpatient setting in the inner city. I mean, they're really made for the hospital and so on, or neurosurgeons, et cetera, so they can do it. But now that they're part of the culture and they're working for us, you see, now we're designing the hospital. Opening a hospital from scratch and a high acuity one requires a tremendous amount of what we call mock operations, which means that integrating people. If you have not worked with people, imagine you show up at work, you have never seen anybody. You have never seen the nurse. You've never seen that computer. You've never seen the person that reads them. You have never seen, when you call and say, "I need an x-ray," no one knows each other. That is what the difficulty is, so we have to build that and imagine doing that if you have an ICU, so therefore a lot of that.

So this is why the hospital, it's again, we will see a first patient March 29th of 2022, rather than February 1st, which is really not much of a difference. Again, it had to do with when the hospital's ready... The hospital's actually going to be ready by the end of January. You can't just walk in and say, "Okay, where's the Da Vinci robot? Lend me a bot." You have to run a tremendous amount of mock operations to make sure we are safe, that we're working as a team, and that everybody feels secure. In fact, just like the post assembly lines and anyone can stop it, and we have a phased-in approach, for example, to London. The first week, we'll see patients. Second week, no surgery, just medical patients, and then third week, we are going to do cardiac cath and EP, some interventional radiology, day surgery and then by about February 12th, we'll start maybe doing more complex surgery.

But any time in that interval of progression in our speak up culture, they can push the button, say, "I'm not ready to going next because I don't feel comfortable that we are a safest place on the planet." Therefore, although we have a plan, anybody can move that plan in different ways. That's in summary. I can only tell you that we've recruited amazing leaders. All the institute chairs have obtained academic appointments within Lerner College of Medicine, mostly at the professor level, and therefore, again, we've recruited good people and the idea is just like we open, we create opportunities. My role, I have been there, and again, we'll be there for another couple of years, is to really create opportunities for people to lead and really be very independent of me so that they now will have the responsibility of giving their Cleveland Clinic culture to their subordinates.

Brian Bolwell, MD:It's a fascinating story, it really is, and congratulations on all the success so far. As somebody as someone who's been involved in buildings and construction for most of their career here at space committee, as well as we opened a new cancer center for our listeners a few years ago here on campus, turning things on is not a light switch. You have to, number one, get people used to what the facility is. People, the nurses need to know where the supplies are. You've got to get things stocked, but then inevitably once you start performing clinical care things come up, and things that you didn't, despite all of your planning sessions, didn't plan on, will come up. They will arise. There will be challenges. The main thing is to listen to all of your constituents and be okay making changes, because this is not a situation where you hold onto steadfast ideas if they're not working.

You've got to be pretty nimble and pretty fast and you've got to be very responsive because at the other end, you've got all of your clinicians trying to take care of sick people, and you need to help them do their job. This becomes really a very exciting part of the whole process because there are new things that occur that require a lot of quick thinking, but it sure is a great way to demonstrate transparency and other leadership skills. It's going to be an exciting time for you and everybody associated with Cleveland Clinic London.

Tommaso Falcone, MD:Yeah, and I think that, as you said, you had a completely new, big building. I mean, at least the advantage was your team worked with each other already, and that always helps, because then you can... I mean, you were giving dangerous drugs all the time and that team says, "I know what I'm doing." One of the challenges for us is that these teams have not worked together. Many, many hospitals, even for Avon, 70% of the employees that came in there, nurses, et cetera, actually had worked together at Lakewood or something of that nature. I think what's important for us is that we have to build that mutual trust, and that's a critical part of it.

To build mutual trust, you have to put in a particular situation where people say, "Okay, let's work together and I can trust you because I know you're honest. I know that you're a fair person. It's not a blame culture. I know that I can speak up and not get shot down." This concept, I don't know if you've explored it before with other people, that I'm trying to build, which again, I learned myself, is this concept of psychological safety within the group. It's always interesting how you think, and I'm sure I'm easy going.

I mean, I build this culture of psychological safety and then you do a survey and you're never as good as you thought you were. Say, "Wait a minute, I'm pretty easy going. I don't retaliate or I don't think I'm overly critical, but some people will see it that way and you'll have to adapt because psychological safety within a high acuity setting is very important, and so that's my next phase. If you ask me what I'm working on for my self-improvement is to continue to do my best to establish this cult, this situation of psychological safety. I don't know if you've seen that in your leadership career as well.

Brian Bolwell, MD:Yeah. We talk about psychological safety a lot. There's a, a wonderful book authored by Amy Edmondson about it, and she quotes several studies that show that psychological safety is differentiating in terms of having a successful organization versus those that are not. I think it's just very, very important. The other thing you talked about was the fact that your teams are going to be in their infancy and how important it is to build trusting teams. At the end of the day, work is about relationships, and so you've brought up trust several times, and just building relationships and creating a sense of you can count on other people and they're going to come through for you.

Brian Bolwell, MD:Certainly, I know, Tom, that you own this personally, that if you say you're going to do something, you're going to do it, and you're going to get back to people if you say you're going to get back to people. These may not sound overly profound, but it turns out that they're not all that common, and to simply do stuff like that and to generate trust is an essential leadership skill, which you've always had. As we're winding up, do you have any final thoughts about your own personal leadership journey?

Tommaso Falcone, MD:Well, like I said, the journey... always people say, in life, everything is the journey, and it is true. Again, it's just different skills. Someone... I mean, obviously you're more interested in the insight of what skills that you have to teach people and write about it. My interest is not obviously academic in leadership. It's more in practical, like what are the skills that you need to get the job done? That is a learning, so I'm more of a student than I am as a person who investigates and say, "Okay, you need these skills." But of course, that's why we need a group of people like you and the organization behind you to teach us these things.

Because again, I still enjoy my research and other aspects and it's not on what's leadership. It's still on endometriosis and fibroids. Therefore we need a group, and in London we intend to do it and believe me, people are interested in London, going to London, England for leadership courses, more than they are sometimes to come to Cleveland, Ohio. But within the organization, we do need a group that will say, "Okay, you know something? We're in this for you personally. It's all about personalized. You talk about personalized medicine, personalized leadership skills. We need to tell the leaders what they need. We learned by fire, but that's really not the way anymore.

It's just like when I learned surgery, see one, do one, teach one, that's gone completely. That's unsafe, was never good, but we already know that it's not the way to treat patients. Certainly I wouldn't want someone to operate on my wife or my mother with that attitude. The same thing goes with leadership. It's just not something that you say, "Look, oh, this is interesting, psychological safety, I guess I should have learned that or something." I think in the modern era for... and I hope it's going on more than when we became leaders, that people are being taught. There's a new chair, for example, Women's Health Institute. She came from Methodist in Houston, but different culture, different thing. I'm hoping that nowadays, we just don't say, "Okay, go ahead. Good luck. Come and see me next year for your APR, for leadership."

I think that I'm hoping that it's changed and that I'm hoping that resources will be given so that all the leaders, and it's not again, "Okay, you've trained in these three things, please go away and come back." I mean, it has to be forever. So the journey of leadership will change and depending on where people are, and I'm hoping that nowadays we've made it more formal than the way we learned, because we made a lot of mistakes, as you know.

Brian Bolwell, MD:Well, we have made it more formal. We have a pretty formal onboarding process, and the goal, of course, it seems like every one of these podcasts, I say, "I have a PhD in making mistakes," and hopefully that our successors will do a little better than that. A lot of really, really key and important points for our listeners during this podcast. A lot of great insight from Dr. Falcone, and Tommaso, thank you so much.

Tommaso Falcone, MD:Thank you

Brian Bolwell, MD:Everybody out there, have a day.

Brian Bolwell, MD:To our listens, we welcome any topic ideas you may have for future episodes, comments and questions about this, or any past episodes. You can let us know by emailing us at executiveeducation@ccf.org. Thank you very much.