Editors’ Note

Michael Dowling has held his current post since January 2002, after having served as the health system’s Executive Vice President and Chief Operating Officer. Before joining North Shore-LIJ in 1995, he served in New York State government for 12 years, including seven years as State Director of Health, Education and Human Services and Deputy Secretary to the Governor. He was also Commissioner of the New York State Department of Social Services.

Institution Brief

North Shore-LIJ Health System (www.northshorelij.com) is the nation’s second-largest, nonprofit, secular health care system. It includes 16 hospitals throughout Long Island, Queens, Staten Island, and Manhattan; long-term care facilities; The Feinstein Institute for Medical Research; five home health agencies; three trauma centers; the Hospice Care Network; and more than 400 outpatient locations across the region. In addition, the Hofstra North Shore-LIJ School of Medicine admitted its first class of 40 students in August 2011. Excluding its affiliate organizations, North Shore-LIJ facilities house more than 5,600 hospital and long-term care beds, more than 9,000 physicians, more than 10,000 nurses, and a total workforce of about 46,000 employees.

How do you maintain consistent performance throughout the North Shore-LIJ Health System and avoid becoming complacent while receiving so much positive recognition?

Recognition is nice and very much appreciated but staying humble and reality focused is important. You have to constantly be aware of the dangers of complacency. You have to maintain a constant discipline and recognize that there is always a huge gap between where you are and where you wish to be. Recognition, in many ways, just means that there is enormous potential for growth and improvement.

At the end of the day, you are doing well if your quality results are excellent, your customer service statistics are the best, and your financial numbers are solid. If you can maintain those results over time, you can feel reasonably positive but you should never get over-confident.

How closely integrated are the hospitals within the North Shore-LIJ Health System?

We are the only truly integrated system in the region. All of our facilities – inpatient, ambulatory, long-term care – are integrated. There are common, universally accepted, and standardized metrics across all entities. All back office functions are centralized with unified leadership – finance, quality, human resources, education and training, purchasing, contracting, legal, real estate, etc. We are not a collection of individual separate entities – we are one consolidated company with multiple integrated entities.

The system has single administrative and clinical leadership as well as a unified governance. We have clinical service lines. For example, the lead person for obstetrics oversees policy, strategy, and standards for OB across the whole system. This avoids unnecessary duplication and redundancy, and inappropriate internal competition.

An organization structured like this, which I believe is the correct way to do it, requires people who understand matrix management, collaboration, and the importance of teamwork.

How do you define and quantify quality within the system?

The provision of care should meet the optimum standard, should be provided in the proper location, and should be delivered with maximum compassion and caring. The focus on quality over the past decade by the leading health care organizations and the emphasis placed on it by payers and regulators has led to major improvements in multiple areas – stroke care, cardiac care, etc.

Quality cannot just be a program or a department – it has to be everyone’s job and has to be ingrained in the culture of the organization. A major focus in our organization is on mortality, sepsis (where we are a national leader), and end-of-life care.

Another positive quality trend is the provision of care in the most appropriate environment. Patients who do not need to be in a hospital are given care in an ambulatory location or in the home. This can make a big difference in quality outcomes. How organizations get paid can also have a major impact on what is done, how much is done, and where it is done. Financial incentives affect behavior. This is one of the reasons I believe we have to move away, over time, from fee-for-service to new forms of reimbursement such as bundled payment and capitation.

Advances in medicine and care bring about longevity in life. This creates another set of challenges related to end-of-life care. Are these being effectively addressed?

No. The Accountable Care Act doesn’t fully address all of these issues.

As we try to reduce the overall cost of care, it’s important to remember that the bulk of the cost is spent on individuals at the end of life, suffering from multiple chronic illnesses. The question is how we deal with chronic illness, which is multifaceted and requires a multidisciplinary approach to care. There is a lot of work being done on this but no one has fully figured out how to do it. This is one of the single biggest challenges for all health care systems.

It’s not just about hospital care; home care is also crucially important. Under many circumstances, it requires the provision of services beyond the delivery of medical care – social services, family support services, and others are equally important.

Will the need for hospitals diminish over time?

Hospitals will still be an important part of the delivery system, but we won’t need as many hospitals as we have today; we’ll need better hospitals that are more focused and that deal with the seriously ill. What goes on in the hospital will be much better coordinated with what goes on outside the hospital. Hospitals will be a key part of the continuum of care – but only a part; they will not be at the center of care as in the past.

Is top talent still coming into the profession?

I believe so. The number of individuals applying to medical schools and nursing schools continues to grow.

The challenge is how we educate and prepare people for the world of the future. Education and training needs a major transformation because the demands of the future will require employees to be more analytical, more team oriented, have more leadership ability, be more sensitive to the diversity of the populations to be served, and understand the role that lifestyle and behavior play in our ability to improve health care outcomes. This is one of the reasons we started our own medical school – with its unique curriculum – and our own internal Center for Learning and Innovation (CLI), which emphasizes the use of simulation as a training tool.•