By Lauren Phillips

West Chester, Pa., and Cleveland, Ohio, are about 410 miles apart. Yet Pennsylvania residents have ready access to Cleveland Clinic cardiac specialists and expertise thanks to a quality-focused partnership-and win-win business affiliation-between the brand-name organization and 220-bed Chester County Hospital.

To boost the size, quality, and reputation of its clinical programs, The Chester County Hospital and Health System, West Chester, Pa., has historically sought out partners on the cutting edge. For example, faculty from the University of Pennsylvania School of Medicine run the health system's radiation oncology and radiology services. Likewise, pediatricians and neonatologists from Children's Hospital of Philadelphia operate Chester County Hospital's pediatrics unit and Level III NICU.

So when Chester County Hospital decided to broaden and deepen its cardiac surgery services five years ago, it turned to the No. 1 medical center for cardiac surgery in the country, 16 years running: Cleveland Clinic.

Cleveland Clinic was in the process of growing its unique heart surgery affiliate program beyond state borders. Since 2004, Cleveland Clinic has extended its brand from seven Ohio hospitals to six non-Ohio hospitals. Today, one of those affiliates is Chester County Hospital.

The Business of Quality

Cleveland Clinic's affiliate program was launched in response to a perceived need in the marketplace, says Joseph G. Cacchione, MD, FACC, interventional cardiologist and chairman of business operations and strategy, Miller Family Heart and Vascular Institute, Cleveland Clinic.

"Hospitals were asking us for oversight on quality issues, and we have come to believe that it is important for us to extend our quality reach as a national resource," he says.

Cleveland Clinic proactively determines which markets would be wise choices for affiliate programs. "We select quality hospital cardiac programs in those markets and provide the programs with management services, including clinical direction, quality assurance, and access to the most sophisticated technologies and techniques," says Cacchione. "All affiliate surgeons are credentialed by Cleveland Clinic and participate in our training, conferences, and educational programs."

While boosting clinical quality at the local level is the mission-based goal of the affiliate program, Cleveland Clinic is also meeting revenue goals.

"We charge for the transfer of intellectual property-for helping programs and surgeons develop capabilities," says Cacchione. "Also, more patients from the markets where we have affiliates are coming to Cleveland Clinic for care; if something can't be done locally, we're thought of first for that advanced care."

In return for an annual affiliation fee, a hospital can use the Clinic's branding and menu of services-some off-the-shelf, some tailored specifically for the organization. These include:

  • Quality oversight
  • Imaging connectivity
  • Overreads on imaging
  • Morbidity/mortality reviews
  • Preferential pricing for certain implanted devices
  • Help with coding
  • Documentation improvement
  • Radiation safety
  • Recruitment/placement of physicians

In addition, Cleveland Clinic sponsors an affiliate retreat every year, during which staff from affiliated hospitals share clinical and administrative best practices. Cleveland Clinic cardiologists and cardiac surgeons travel to affiliate hospitals for educational grand rounds, hold monthly meetings (primarily via webinar) with affiliates, and visit each site at least twice a year.

Exacting Standards

Before Cleveland Clinic offers affiliation to a hospital, the facility's administrators and clinicians take part in what Cacchione calls "a deep dive" due diligence period.

"We send a team out to take a close-up look at the clinical program and at strategic and operational issues," he says. "We assess the quality of the hospital's programs, processes, order sets, physicians, and management team. We look at the organization's strategic focus, and we do a competitive assessment."

Affiliate agreements are for five or seven years and can be renewed. They can also be ended early, if a program is not meeting the Clinic's quality standards, says Cacchione.

"We generally oversee the performance data, and when there seems to be a problem with a procedure or an individual, we do a deep dive with the affiliate and create a plan of action to improve the outcome," he says. "The affiliate is responsible for helping to drive these improvements at both the hospital and physician levels. In some cases, the Clinic and hospital work through the existing peer review process of the local medical staff bylaws to make necessary changes."

For most affiliates, the program has meant an improvement in quality, due in part to the standardization of protocols. One organization went from an annual mortality rate of 7 percent to 0.8 percent for cardiac patients, says Cacchione. Cleveland Clinic publishes all outcomes annually for each program. Chester County Hospital has posted its 2010 cardiothoracic surgery outcomes on its website.

Leveraging the "Best Brand"

In some cases, like Chester County Hospital, affiliates also show an improvement in volume. Since beginning its affiliation with Cleveland Clinic in 2006, the hospital has performed 721 cardiac procedures and 141 thoracic procedures, with volume rising steadily in each category annually. For example, there were eight aortic valve replacements in 2009 and 15 in 2010.

"We started our cardiac surgery program around 2001 and have slowly ramped up," says Paul F. Huberty, MBA, MS, senior vice president, strategic planning and marketing, Chester County Hospital. "Our goal is 250 surgeries a year, and we're up to about 200 now. We're in a smaller market, so we didn't see a significant jump in volume immediately, but without the relationship with Cleveland Clinic, we would definitely have a smaller program."

However, for Chester County Hospital, as for Cleveland Clinic, quality comes first.

"We wanted to learn and adopt best practices," says Huberty, referring to the reason for affiliating with Cleveland Clinic. "Our two cardiac surgeons have faculty appointments at the Clinic and are able to develop really strong physician-to-physician relationships with their peers at the top heart program. The Clinic works with our surgeons and staff on a regular basis; it monitors our outcomes monthly to make sure that our program is meeting its standards in every way. We also participate with the Clinic and with the other affiliates in monthly video conferences and meet with Clinic researchers."

The result, according to Huberty, is access to state-of-the-art cardiovascular care unprecedented in a community setting.

For example, Cleveland Clinic is participating in the clinical trial of percutaneous treatment for aortic valve stenosis (going in through a catheter without opening up the chest) as an alternative for high-risk surgical candidates. "I was out at the Clinic for a couple of days recently and was able to hear directly from Clinic physicians about the clinical trial, their experiences, and outcomes," says Huberty. "We brought that information back, talked about it with our leadership, and asked: 'Is this something we need to start planning for now, or should we wait a little while?'"

"Chester County," continues Huberty, "is always looking to differentiate what we do here from all of the other hospitals in the very competitive Philadelphia market, and to leverage the best brands in health care."

As an affiliate of Cleveland Clinic, that's exactly what the hospital is doing. In 2009, the Society of Thoracic Surgeons' Adult Cardiac Surgery National Database ranked Chester County Hospital in the top 10 percent in the country; the society gave the hospital its highest rating (three stars).

Getting All Parties to Understand the Nature of the Agreement

There are challenges on both sides. For Cleveland Clinic, the first is handling a dramatic growth in demand from potential affiliates-"a good problem to have," admits Cacchione.

The Clinic has already expanded its affiliate program from cardiac surgery to cardiovascular medicine and is looking hard at neurosciences and cancer care. It's also talking with potential affiliates overseas.

The second challenge is overcoming some local physicians' fears that Cleveland Clinic is going to prescribe how and when they can act.

"That's not what we're about; we're about creating the right environment for quality. I like to say that, 'Our noses are in, our fingers are out,'" says Cacchione. "We provide them with resources and with oversight, but not with actual management; they have to own the program. So early on, some physicians feel like Big Brother is watching, but over time, they come to see us as a resource and are very happy with the affiliation."

For Chester County Hospital, ironically, communicating the advantages of the Cleveland Clinic affiliation to the public is the hardest part. The hospital uses both its own logo and the Clinic's, but it is hard to get across what the relationship means in a couple of sentences or a 20-second commercial, says Huberty.

"We use all approaches-traditional advertising, online advertising, radio, billboards, and outreach. We have print materials that ask, 'What Does this Affiliation Mean to You?,' and we take those materials to all kinds of venues: our own events on-campus, senior centers, assisted living communities, local YMCAs and fitness centers, and businesses."

Start with Quality and Never Let Up

Other "national brands" besides Cleveland Clinic, such as Mayo Clinic, are also starting their own affiliation programs.

When asked what advice he would give to community hospitals interested in pursuing such a partnership, Huberty says it's important that the hospital and the service line are operating at the highest levels of quality and patient satisfaction.

"Potential partners are going to be looking at your data closely and asking tough questions. They're not going to want to lend their brand or expertise to a hospital that doesn't have good quality to begin with," he says.

It's also important, Huberty adds, to think about the qualifications and criteria for a good partner. Not every partner is going to offer the same fit in terms of mission, culture, leadership, or strategic objectives. You need clear goals on both sides that everybody understands, and you need to make sure you don't have competing interests.

"You want to learn as much as you can about the organization and, perhaps, even try dating a little while before signing a multiyear agreement," he says. "What are the other organization's goals for the relationship? Is it willing to commit the necessary time and resources to make the relationship work?"

Cacchione would be the first to agree. From Cleveland Clinic's perspective, the keys to success are "the services we deliver and the continual interaction."

"This is not about posting our sign and walking out the door and collecting money for the brand. It's about ongoing, active attention," says Cacchione. "It takes resources and due diligence to maintain the relationship and provide continued value to the host program."

Lauren Phillips is president, Phillips Medical Writers, Ltd., and a regular contributor to HFMA (

Interviewed for this article:

Joseph G. Cacchione, MD, FACC, is interventional cardiologist and chairman of business operation and strategy, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland (

Paul F. Huberty, MBA, MS, is senior vice president, strategic planning and marketing, The Chester County Hospital and Health System, West Chester, Pa. (

Publication Date: Friday, July 22, 2011