Health system integration is one of the many ways hospitals can meet the mission of advancing health, and there can be wide-ranging benefits – from enhanced economies of scale to pooled capabilities. In this Leadership Dialogue conversation, Tom Priselac, president and CEO emeritus of Cedars-Sinai, discusses overseeing 30 years of growth and integration at the health system, and the perspectives required to integrate across multiple care areas. 

This is an edited conversation. To watch the full video version, please visit https://www.youtube.com/watch?v=6_PsrrmpsAc

Tom Haederle

Integration - when a hospital joins a health system to benefit from enhanced economies of scale and pooled capabilities - is one of the many ways that hospitals meet the mission of advancing health. Bringing formerly independent hospitals together under a new administrative umbrella can be a delicate dance and must be done carefully for the arrangement to work and the integration to benefit all care providers and their patients.

Tom Haederle

Tom Haederle

Tom Priselac is president and CEO Emeritus of Cedars-Sinai, where he retired in September after more than 30 years of overseeing its growth from a regional hospital to one of the largest and most influential health systems in the country. And now, to Dr. Conroy.

Joanne Conroy, M.D.

It's great to be with you. I'm Joanne Conroy, CEO and president of Dartmouth Health and the current chair of the American Hospital Association Board of Trustees. I'm looking forward to our conversation today with my friend and colleague, Tom Priselac, who will share his insights on running an integrated health system. He's been at it for 30 years and he is an expert on this topic.

Joanne Conroy, M.D.

He knows his stuff. Tom is president and CEO emeritus of Cedars-Sinai Health System, and despite having just transitioned into retirement last month, he was kind enough to join us today. Tom led the transformation of Cedars-Sinai from a regional hospital into a renowned academic health system. He has spent much of his career championing the important role of health systems and, of course, advancing health for those patients and communities served by Cedars-Sinai.

Joanne Conroy, M.D.

So welcome Tom, who knows this topic better than anyone. And we'll start with a broad question to frame the discussion. How do you define what it means to be a health system, and what are the benefits and what are some of the challenges?

Tom Priselac

Well, I think for me, what it means to be a health system is essentially each of the institutions that become a part of the health system, asking themselves whether it's the founding institution as it was in our case, or affiliate organizations that have become part of the Cedars-Sinai Health System or the organizations with which we have joint ventures, which is another vehicle we've used to build our system.

Tom Priselac

I think it really comes down to each of the institutions asking that core question, what is the path forward for my institution that will allow that institution to best serve its community and carry out its mission? As we've gone through the development of the system in whatever structural form, we've always made that an important part of the consideration of, in the case of Cedars-Sinai, asking the question of given the mission of Cedars-Sinai as both a major academic medical center and a full service community hospital to about 3 million people in Los Angeles.

Tom Priselac

The whole purpose in creating the system, and this is literally embedded in the mission statement of the organization. The system exists to optimize the ability of the member institutions better serve their community. That aspect of what I just described applies whether the integration has been horizontal or whether it's been vertical, with integration of our physician network over the years.

Joanne Conroy, M.D.

I think that's incredibly important because health systems are there to really serve their members and their communities, because we don't always actually take care of patients at the health system. They're actually taken care of at the member sites. So when you talk about the commitment to quality and the commitment to excellence, when you bring in new members, that's a delicate balance between imposing something on a member versus creating it together.

Joanne Conroy, M.D.

So, you know, what's been your approach to really try to manage that?

Tom Priselac

That's a great question. And the characteristic you just described of what I guess I would call co-creating the vision of what it means to be part of a system and be a system. That philosophy of doing it in a co-creating way, as opposed to a kind of a top down. We know the answer in your local community way.

Tom Priselac

The former is very much the path that we have taken. And the same is true whether that's the development of partnerships and affiliations with hospitals or other health systems, or again, with the multiple physician organizations that have become part of our physician network. We do a lot of due diligence on the front end to number one, make sure there's a very much aligned set of core values that whether, again, whatever the entity is, that's becoming part of the system.

Tom Priselac

We really start there and spend a lot of time on that question. And we spend a lot of time talking through the philosophy of the institution, which is to take advantage of economies of scale and economies of capability. An important element, I think, that doesn't necessarily always get the same attention. And making sure that there's a common understanding between us and the incoming organization about what that means for them.

Tom Priselac

Back to the point I just made, how the approach that we take in that regard is going to allow that organization to better fulfill its mission, and how that affiliate becoming a part of the institution will allow Cedars-Sinai to better serve its mission.

Joanne Conroy, M.D.

Let's talk a little bit about recruiting clinicians, because I think there's been a little bit of a shift. I know that historically, when there was an academic medical center, you know, people didn't want to leave what was the comfortable academic medical center to actually provide services outside of that organization. I think over the last ten years that's become a little bit easier.

Joanne Conroy, M.D.

How do you actually use this concept of a health system to actually better recruit clinicians? I can tell you our parking is horrible here. So a number of our clinicians are happy to work at our other hospitals, where the operating room is a little bit more efficient, and the parking lot always has spaces. So how do you manage that with your health system?

Tom Priselac

Well, with regard to physicians being recruited here at Cedars-Sinai, first of all, it starts with what's the primary career interest of the physician being recruited? For those for whom their primary career interest is more research related. You know, the conversation there centers around things like access to diverse populations, which is now finally being recognized as how important that is on the on the research agenda.

Tom Priselac

And so, Los Angeles being one of the most diverse cities on the planet, we offer that kind of opportunity to academic physicians. And then secondly, with those physicians who have a more primary clinical orientation, the opportunity for the existence of the system, especially for the physicians who are providing the tertiary and quaternary services. The conversation really stems around how the existence of the system can facilitate the ability of Cedars-Sinai to be increasingly the place where more tertiary and quaternary services, which are of particular interest to that particular physician or surgeon, would be of most interest.

Tom Priselac

And so, there's an effort to try to align the purpose of the system with what the professional interest of the clinician or researcher involved.

Joanne Conroy, M.D.

How do you actually manage? And this is not uncommon for a new member hospital to actually look to the largest member of the organization to help them establish a new service or expand a service. Where are those decisions made in a health system? And there's got to be some investment because they're hard to stand up, and they're not always as maybe as efficient as it may be at a higher volume institution.

Tom Priselac

That process actually starts during the due diligence effort. And we try to take a very respectful approach with regard to clinical integration between Cedars-Sinai and the affiliates. We're very respectful of the capabilities and quality of the medical community and the local affiliate, and very consciously avoid trying to suggest that we're going to come in and fix a problem.

Tom Priselac

It's really a question of how can Cedars-Sinai and our clinical capability complement what already exists in the institution and builds on it for the benefit of that local community? By the way, you know, implementing that really gives emphasis to the importance of the individual who serves as the CEO of that affiliate organization, because that CEO has to have the kind of trusted and trusting relationship with their medical staff to be able to hopefully guide them through both an understanding and not just an acceptance, but a welcoming of the kind of relationship that I just described.

Tom Priselac

So, you know, and what we would typically do is our clinical leadership engaging with clinical leadership from the respective affiliate. And essentially, I guess you could call it going through an inventory. Before we actually proceed with the affiliation, there's a very clear understanding of where the priorities will be and how that would go about, how that might be executed via physicians that would be recruited here to Cedars-Sinai and then providing those services on some basis in the affiliate.

Tom Priselac

But in other situations, what we've done is we've taken the recruitment ability that an academic medical center has to be able to help those local communities be more successful in recruiting a more experienced and more capable physician or surgeon, depending on the specialty service involved.

Joanne Conroy, M.D.

You know, health systems, as we get larger, have a much broader community responsibility. And I know we are investing in transportation, housing, child care, really in a much broader footprint than necessarily one facility. What are the type of things that communities come to you and want your partnership on that actually benefit the broader health of the community?

Tom Priselac

One is the clinical capability. And so part of the strategic planning of the system is answering the question, how are we going to raise the clinical capability in each of the respective affiliates through whatever physician recruitment approach along the lines of what I just mentioned. So the clinical capability questions there, for some of the affiliates, being part of an organization that has the kind of balance sheet that the larger organization has, whether that's allowing the institution to be more cost effective and have better access to resources because borrowing costs might be lower, is maybe an example on that side.

Tom Priselac

In some of the relationships the research capability of the institution and how that can facilitate the availability of clinical trials, especially in an area like cancer, which may be of more interest and need in one community versus another. And then finally, each of our institutions as not for profits, all have community benefit missions. You know, over time, one of the things that that we carry out is the integration effort on the community benefit side as much as anything else, to just make sure that as each of the institutions approach their individual community benefit missions, we're doing it in an aligned way and looking for the commonalities of what kind of community benefit activities would be

Tom Priselac

most impactful over the geographic footprint of the system. And the example I would give in that regard in Los Angeles today, we're all familiar with the challenge of homelessness - in America in general and certainly here in Los Angeles. And so in the area of community benefit work related to homelessness, whether it's grantmaking or programming that might go on in each of the institutions, and sharing information, sharing knowledge about best practices and what we have found to be the most effective strategies in that regard.

Joanne Conroy, M.D.

Yeah, you're right. You know, every single community just seems to have their own specific challenges. Talk a little bit about quality and patient safety. How do you, you know, bring people together and have them kind of co-create a quality safety culture? You know, I've said that the system is there. Its role is to monitor, but the quality is really kind of owned by the combined organizations.

Joanne Conroy, M.D.

So how have you kind of structured bringing people together and what do you think has been the most effective?

Tom Priselac

Yeah. So I guess I'd begin by reflecting the overall philosophy we've taken, which is the purpose of the system, is to assure the optimal success of each of the individual members. We're very much interested in strengthening and not disempowering the local hospital or the affiliate hospital, especially issues like quality. When we bring organizations into the system, part of that due diligence is to make sure we're satisfied it's already a high quality institution.

Tom Priselac

And the question is, how can becoming part of that system help make it better? We've taken the approach of in certain areas to pursue a more what I would call a shared services approach. And in others, we're using what we call a collaborative approach. And with regard to how we approach managing for quality, we use the collaborative structure.

Tom Priselac

What does that mean? What that means is that we've gone through a process of, on the one hand, identifying a set of common measures of what quality means across the system and making sure that each of the institutions have focused work that is addressing what those commonly identified quality goals are for each of the institutions, but also leaving room for the local institution to continue to pursue quality priorities that are relevant and unique to that particular institution.

Tom Priselac

We establish what I'll call a common language, a common platform for measurement, agree on how that measurement is going to take place, and then essentially we use the collaborative model and the knowledge sharing that goes on in the collaborative discussions among each of the management teams from the respective institutions to be able to advance the individual and therefore the collective performance of the system.

Joanne Conroy, M.D.

You know, you bring up a good point that, you know, you can't actually run it centrally. But one thing that is very evident when there's an issue is the resources when you can pull everybody from across the system to address an issue are incredibly powerful. I think we had an organization once that was going through a very rough Joint Commission visit. And I think on day two, half the system swooped in there to actually assist the team that was there and say, how can we help you?

Joanne Conroy, M.D.

And, you know, it's interesting you don't appreciate the power of the system until you actually need to use it. And it's often just all of a sudden, instead of having two people on your team, all the sudden you look behind you and you have 100. It makes people both confident and much more effective.

Tom Priselac

That's an example of what I meant earlier about systems bringing economies of capability or scaling capability within the institution. In a lot of the public policy discussions there's really a lack of appreciation, I think, from people outside of health care delivery about what that means and how that can enhance the ability of an institution to provide high quality care.

Joanne Conroy, M.D.

Well, Tom, I want to thank you for giving us some of your time today. We really appreciate your valuable insights and your expertise, and we wish you the best in retirement. But I have a feeling your dance card is going to be pretty full. Probably already is with people that want you to give them advice about, you know, building a health system that serves the needs of the communities.

Joanne Conroy, M.D.

Thank you Tom, again.

Tom Priselac

Thanks, Joanne.

Tom Haederle

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