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CHAPTER EIGHT
The single most important thing I’m doing is engaging the staff.”
“
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IN 1988, THE AMERICAN HOSPITAL ASSOCIATION HONORED METROHEALTH WITH THE FOSTER MCGAW PRIZE. The award is bestowed each year on a hospital—public or private—for outstanding community service. MetroHealth was chosen that year over a prestigious list of finalists including Beth Israel Medical Center in New York, Los Angeles County/USC Medical Center in California, and Mount Sinai Medical Center in Illinois.1 The bigger accomplishment, though, was the work Henry Manning did to earn the national recognition.
After serving as deputy commissioner of the hospitals of the City of New York, Mr. Manning arrived at MetroHealth in July 1970,2 just as the iconic new twin hospital towers were completed. He survived the fiscal crisis of his first full year at the helm and, in that same year, opened one of the country’s first burn centers. (See Chapter Five.)
But one of his biggest tasks early on was completing the merger of MetroHealth with other area health institutions. The effort was designed to provide a complete continuum of care, avoid duplication of services, conserve resources, and use the savings to expand primary care in the community. The merger, which included Highland View Hospital, the long-term care facility Sunny Acres and its clinics and programs, and the county nursing home, began in 1971. That fall, it was approved by voters along with a tax increase that would provide $37 million for capital improvements.3
Over the following years, the health system under Mr. Manning thrived as he led the organization to new heights. Together with the board and staff of MetroHealth, the list of accomplishments included opening the Kenneth W. Clement Center for Family Health Care in 1976 (see Chapter Six), completing the merger with Highland View Hospital in 1978, opening the Neonatal Intensive Care Unit in 1979, and establishing Life Flight, the area’s first medical transport service, in 1982 (see Chapter Five). All of that was on top of the outreach programs that led to the McGaw Prize: providing healthcare and support to seniors, pregnant women, children with disabilities, and people without homes.4
“[Y]ou wonder who would be serving those folks if Metro wasn’t,” the chair of the prize committee said when the award was announced. “They are very effectively reaching a lot of folks who would undoubtedly be less well served.”5
Despite his outstanding leadership and achievements, Mr. Manning’s career at MetroHealth ended suddenly, amid controversy, in 1993.
“The abrupt departure came because the trustees and county commissioners say they recently discovered that when Manning set up the private MetroHealth System in 1991, he effectively wrested control of the county hospital from the publicly appointed trustees,” the Plain Dealer reported in a March 1993 article that announced Mr. Manning would step down on June 30.6
His supporters contend the move to a private health system was a way to modernize the corporate structure, keep politics out of the hiring process, and focus instead on applicants’ qualifications.
“Board members saw Manning as one of the main reasons that the last-resort hospital for the poor in Cuyahoga County was an equal to the more prestigious Cleveland Clinic and University Hospitals,” according to a later Plain Dealer news story.7 That article also detailed Mr. Manning’s vision of creating a public hospital that appealed to privately insured patients who could help offset the expense of charity care for the poor and keep the county subsidy (taxpayer money) low.
During Mr. Manning’s tenure, MetroHealth grew into the largest public healthcare system in Ohio.
During Mr. Manning’s tenure, MetroHealth grew into the largest public healthcare system in Ohio.8 Incredibly, it added patients more rapidly than the Cleveland Clinic. In addition, Mr. Manning improved the health system’s financial footing by increasing revenues, not cutting expenses.9 His leadership and achievements were acknowledged in 1999 when the twin towers at MetroHealth were named the Manning Towers. A few years after his departure from MetroHealth, at the age of 62, Mr. Manning died of complications from lung cancer.
In 2011, he was inducted into the MetroHealth Medical Hall of Honor.
“He insisted that public care should not be inferior to that of private pay and insured patients,” said retired Chair of MetroHealth’s Department of Dentistry, Leonard P. Weiss, who nominated Mr. Manning for the honor. “And thus Cleveland’s public hospital ranked among the country’s finest.”
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Experience in leadership positions at Lutheran Medical Center and University Hospitals in Cleveland as well as at the University of Cincinnati Hospital helped prepare Terry White for success when he was chosen as MetroHealth’s next CEO in the spring of 1993. The groundwork laid by Henry Manning helped, too.
“Henry Manning was a titan,” said Mr. White. “I inherited an organization with a soul and just had to get other people to understand what a wonderful organization it was. The organization had to do it,” he said. “To believe in itself.”
In his first year, Mr. White figured he talked with more than 3,000 employees. What he learned first-hand was that employees wanted “the suits” to understand that listening to the staff led to buy-in from the staff. “What employees really wanted,” he said, “was to be listened to. And taking action on what they said built trust.”10
In addition to his listening tour, Mr. White improved finances at MetroHealth by beginning to sign contracts with managed care providers. Within three years, MetroHealth inked more than 100 of those contracts, which enabled the health system to care for more patients with private insurance.
“I felt the services that MetroHealth offered were very valuable and very unique and high quality and I wanted them to be available to as many people as possible,” Mr. White said.
“This stabilized us financially so we could continue to invest in the quality and growth of our programs. It brought thousands of patients with private insurance to MetroHealth. It was a win-win situation.”
His step-by-step approach reflected his commitment to incrementalism. In one of their early meetings, Mr. White told the medical council, made up of the chairs of each of MetroHealth’s medical divisions: “I won’t take anything to the board of trustees—significant policy changes or anything that could directly or indirectly affect patient care—without your approval.”
“My philosophy,” Mr. White later said, “was that to bridge the gap that often exists between medical leadership and administrative leadership, it’s important that people be empowered to participate in the decisions.”
In 1999, MetroHealth became the first hospital with an Epic electronic health record system in Ohio. Adopting the system helped solve two problems. The first was the inability of primary care doctors working at MetroHealth’s community health centers to connect their patients with specialists on the main campus. With the electronic medical record, there was no longer a need to dictate notes, prepare paperwork, and mail documents, a process that delayed care and sometimes resulted in lost referrals.
Second, the Epic health record system made billing more efficient. The electronic record couldn’t be closed until proper billing codes were added. That ensured that coding was complete—with fewer errors. “And the physicians’ collections tripled in the first year,” Mr. White said.
Mr. White also continued MetroHealth’s push to deliver care to patients by opening health centers in shopping centers, especially centers with nearby grocery stores and pharmacies. With that, families eligible for the federally funded Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were able to one-stop shop for healthcare, prescriptions, and healthy food. These new centers, like the ones he opened at Lee Harvard Plaza and in the West Park neighborhood, also provided plenty of parking.
“People are often intimidated by large medical centers,” Mr. White said, “whereas everyone knows how to access shopping center parking. It made it geographically and psychologically accessible for the people. And that was important to keeping people healthy.”
Long after his departure in 2003, Mr. White kept tabs on MetroHealth, and on Dr. Boutros’s leadership style in particular.
“He understands that quality healthcare not only depends on treatment,” Mr. White said. “It has to do with all sorts of societal issues. And you can’t treat one without addressing poverty and the lack of access to education. He’s taken things that I thought about to a whole new level.”
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With Mr. White’s retirement in 2003, the MetroHealth Board of Trustees promoted John Sideras to CEO. Without wasting time, the health system’s former Senior Vice President and Chief Financial Officer led MetroHealth through a rapid expansion of facilities. That expansion included a new Critical Care Pavilion on the main campus, which replaced a dated trauma center and operating rooms. In addition, the construction of new health centers in Cleveland neighborhoods such as Broadway, Brooklyn, and Buckeye helped Mr. Sideras work toward a goal of making healthcare more accessible.
Mr. Sideras was at the helm in 2005 when MetroHealth held a ribbon cutting for the first phase of renovation of the former Deaconess Hospital, which transformed that facility into MetroHealth’s Old Brooklyn Campus, a center focused on senior health and wellness. He was there that same year when MetroHealth nurses achieved the highest national recognition, the Magnet Award, the gold standard in nursing care excellence. And he was there again, in 2007, when MetroHealth opened the Pride Clinic, the first in the region devoted to serving the health needs of the lesbian, gay, bisexual, and transgender community.
The construction of new health centers in Cleveland neighborhoods such as Broadway, Brooklyn, and Buckeye helped Mr. Sideras work toward a goal of making healthcare more accessible.
Mr. Sideras also worked with then–US Senators Mike DeWine and George Voinovich and then-Governor Bob Taft to write and lobby for legislation that increased federal funds for indigent care. That work resulted in billions of dollars, not just for MetroHealth, but for all public hospitals in Ohio.
Two other points of pride highlighted Mr. Sideras’s years as CEO. The MetroHealth Foundation grew to more than $30 million with donations to support research, teaching, and patient care. And his prioritization of Inclusion, Diversity, and Equal Opportunity led to the hiring of Winnell Mason as the health system’s first Director of Diversity.
“We were celebrating some ethnicity, some nationality that reflected who we were, every single month,” Mr. Sideras said. “Prior to that we weren’t doing anything. And the ironic thing was there was no organization around that was more diverse than MetroHealth.
“I grew up in Cleveland. I’m a West Sider. A chance to work in the community was a real treasure for me. It was the most gratifying stage of my 45-year career, without a doubt.”11
His departure in 2008 led the Board of Trustees to hire Mark Moran as MetroHealth’s next CEO.
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As a management consultant for the global consulting firm Booz Allen Hamilton, Mark Moran worked with MetroHealth in the mid-2000s on the purchase of new Life Flight helicopters, a recommendation that saved the health system $40 million.12 Later, the former Case Western Reserve University professor with a PhD in economics worked with the Board of Trustees, physicians, nurses, and administrators to develop a strategic plan for The MetroHealth System. That effort reaffirmed MetroHealth’s mission to provide healthcare to patients regardless of their ability to pay but revealed that the costs of uncompensated care had led to significant ongoing deficits. Mr. Moran believed in MetroHealth’s mission and knew how essential MetroHealth was to Cleveland and, in March 2008, said “yes” when the Board of Trustees asked him to improve the organization’s finances and culture as MetroHealth’s interim president and CEO.
“It was a big commitment,” he said. “It took a lot of soul searching. But I trusted the board. And I thought I could make a difference.”
The Cuyahoga County Corruption Scandal was just one headache Mr. Moran faced during his five-year tenure.
Six weeks into Mr. Moran’s tenure, MetroHealth was contacted by the FBI regarding a corruption investigation. What followed was the imprisonment of two MetroHealth employees who were charged with bribery, conspiracy, and other crimes in a county-wide investigation that came to be known as the Cuyahoga County Corruption Scandal.13 That scandal was just one headache Mr. Moran faced during his five-year tenure.
In May of that year, MetroHealth told 73 employees—a little more than 1 percent of the staff—that they would be laid off. The move was in response to first-quarter losses of $8 million, which followed a loss of millions the previous year.14 One reason for the economic trouble was an increase in uninsured patients who had once been cared for by Mt. Sinai Medical Center and St. Luke’s Medical Center, which closed in 1996 and 1999, respectively. With the recession of 2008, fewer patients were coming to MetroHealth’s emergency department and being admitted to its hospital,15 and more cuts were announced later that year.16 Mr. Moran responded by focusing on operational excellence through the creation of “patient care units.”
“I changed the leadership of the clinical teams to be responsible for delivering care to patients efficiently, with a sharpened focus on budgets,” Mr. Moran said. “I knew the department chairs would assure our research and teaching strengths—MetroHealth is an academic medical center—but we needed clinical and administrative leaders to be operationally oriented.”17
Other cost-saving measures included working with a single manufacturer for electronic implants, for example, which saved the health system more than $1 million. That success was repeated with surgical tools and prescription drugs, too.
And it worked. MetroHealth finished 2008 with a slim profit and, in March 2009, the Board of Trustees named Mr. Moran the permanent President and CEO. He warned then that the health system had another tough year ahead with more layoffs possible.18 But MetroHealth’s finances were rebounding, and the health system announced audited net income of $58.5 million in 2009 and $27.1 million in 2010.19
In September 2011, MetroHealth announced that another 450 jobs would be cut to save $30 million and prevent future losses.20 Three months later, Mr. Moran announced he would leave his post the following March, when his contract ended. The announcement was met with praise from MetroHealth Board Chair Ron Fountain, who commended Mr. Moran for putting the health system on strong financial footing, increasing cash on hand to $376.6 million, up from $250.5 million in 2007.21
“The trajectory of the hospital,” Dr. Fountain said, “is dramatically better today than it has ever been.”22
The following February, at MetroHealth’s State of the System address, Mr. Moran outlined a vision for the future of the health system that included building four new health centers, revamping the main campus, and obtaining health coverage that would help care for more of the county’s uninsured residents. That plan would be one of Mr. Moran’s lasting legacies.23
The effort to help the uninsured was led by John Corlett, Vice President of Government Relations and Community Affairs at MetroHealth from 2011 to 2015 and the former director of Ohio’s Medicaid office. Mr. Corlett led a team of clinicians and administrators to design the insurance plan and presented it to federal and state leaders to develop broad backing for the program. He succeeded in obtaining a waiver from the federal government that allowed MetroHealth to offer Medicaid to about 30,000 more people in Cuyahoga County who previously did not qualify for the government-funded program.24
The program, called MetroHealth Care Plus, made sure those who enrolled had primary care providers, dental care, prescription medicine plans, mental health and addiction services, and electronic medical records, as well as care coordinators who scheduled follow-up appointments and took other steps to keep patients healthy.25
“It fulfilled our mission and saved the hospital,” Mr. Moran said plainly. “It set it up so that [Dr.] Boutros and his team didn’t always have to worry.”
In its first year, the program brought $70 million in additional revenue to the health system while improving the health of thousands of residents of Cuyahoga County.
By reducing emergency department visits and complications often caused when those without insurance delay care, it saved the Medicaid program money, too. And it was so successful, it led to support from lawmakers for then–Ohio Governor John Kasich’s statewide expansion of Medicaid.26
In addition to that, outpatient centers Mr. Moran helped to launch opened in Middleburg Heights in 2013 and in Brecksville in 2016, and his planning laid the groundwork for MetroHealth’s campus transformation.
“I recognize that there have been 28 individuals who have had this leadership position in our 185-year history,” said Akram Boutros, MD, who was named President and CEO in 2013, after Mr. Moran’s departure, “and that our individual efforts must be viewed as one leg in a relay race. That in order to succeed and win, it is not only what you do during your part of the race, it’s critically important to build upon the success of the past runners. And it’s just as important to make sure that the person you’re passing the baton to has as much opportunity to succeed as possible.”27
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Advocating for MetroHealth and its employees and patients wasn’t at the top of Akram Boutros’s to-do list when he arrived as the health system’s President and CEO in June 2013. He didn’t need it on any list. It came naturally. A Plain Dealer reporter assigned to spend time on the job with him ten weeks after he started documented instance after instance of it—how he continually checked in with employees to ask what they needed to do their jobs, how he had misting fans installed in the hot laundry room and sent bottles of icy cold water to the staff, how he supplied residents with cell phones so they didn’t have to sit by a landline waiting for a specialist to return a consult call, and how he fired a manager after employees described the disrespect that person subjected them to.28
“The single most important thing I’m doing is engaging the staff. It’s their organization and they need to make it win,” Dr. Boutros told the reporter. “A 10% increase in output across our employees because of engagement is like for us a $60 million reduction in cost or a $60 million to $80 million increase in revenue.”29
He advocated just as fiercely for MetroHealth’s patients, publicly calling out those who treated them as lesser than or referred to them as “those people,” because many of them are poor, covered by government-funded health insurance, or have no insurance at all.
They are why he committed to rebuilding MetroHealth’s main campus, a hospital in a park, and strengthening the neighborhood around it (see Chapter Ten), why he insisted that MetroHealth help build affordable apartments around its campus (see Chapter Ten), and why he opened the Lincoln-West School of Science and Health, believed to be the first high school inside a hospital, to provide high school students with role models who had careers the students dreamed of having one day.
“The single most important thing I’m doing is engaging the staff.”
Just as important to Dr. Boutros was finding ways to turn what many thought were MetroHealth’s weaknesses into strengths. A prime example is the high percentage of patients MetroHealth cares for who are uninsured or covered by Medicaid, the government health insurance program for the poor, which pays doctors and hospitals less than Medicare or commercial insurance.
Dr. Boutros found a way to make that a win-win-win by drawing down additional federal funds to expand treatment and improve the health of Ohioans through the Care Innovation and Community Improvement Program. This innovative program provides enhanced care to children, pregnant women, those addicted to opioids or other drugs, people struggling with mental illness, and patients who depend on more expensive emergency departments for routine care instead of heading to a doctor’s office. MetroHealth, along with three other health systems in Ohio, not only increased federal funding and improved the health (and lives) of low-income patients, its participation in the program saved the state millions as people on Medicaid became healthier.
Dr. Boutros’s nine years at MetroHealth were also defined by his insistence, unapologetic once again, that a person’s health has little to do with the medical care he or she receives. He made this point loudly and clearly in a blunt City Club of Cleveland speech he delivered on June 7, 2019, titled “What Hospitals Are Getting Wrong and How We Can Fix It.”
He made this point loudly and clearly in a blunt City Club of Cleveland speech he delivered on June 7, 2019, titled “What Hospitals Are Getting Wrong and How We Can Fix It.”
“Here, home to some of the best medical care in the world, we can’t get it right. What’s wrong with us?” he asked the crowd. “What’s wrong is that we continue to believe that good healthcare can be measured by the size of our hospitals and the prestige of those who work inside them. . . . We’ve got to stop promoting what happens inside our hospitals as if it really matters to the health outcomes of our communities. It doesn’t.”30
It was time, he went on to say, to promote health beforehand rather than fight illness later. And he called on others to join MetroHealth in doing that.
“It’s time for us,” he said, “you, me, the business community, philanthropic and civic leaders of Cleveland and Cuyahoga County, to come together and invest in fixing the health-outcome crisis before us.”
Three weeks after that City Club speech, at the health system’s Annual Stakeholders Meeting, Dr. Boutros announced that MetroHealth was creating the Institute for H.O.P.E.™: Health, Opportunity, Partnership, and Empowerment. (See Chapter Seven.)
“It will remove obstacles and help people of all backgrounds reach their dreams—more education, better jobs, higher wages, healthier food, reliable transportation, and adequate housing,” he said. “The things we all need to live a life of opportunity, dignity, and hope.”
Over the next few years, the Institute partnered with dozens of organizations to better the lives of people throughout Northeast Ohio.
Throughout his tenure, Dr. Boutros, publicly and in private meetings, continued to encourage other organizations—businesses, nonprofits, governmental agencies—to join MetroHealth in improving the community.
The closing of his 2021 Annual Stakeholders Meeting speech is just one example. “As you leave today,” he said to the hundreds who turned out on a cool, rainy evening, “we’re asking you to . . . open your hearts, to shine a light on some struggle society has overlooked. And plan to make it right.”31
He called it a great way to celebrate the dream that MetroHealth’s founders made sure came true. “And to remind ourselves, like they did, that we can be the change the world needs.”
It was something he’d been saying all along.
“If we want to change how health care gets delivered in the U.S., the only way we’re going to do that is by influencing others,” he told a reporter from Smart Business magazine in 2015. “That’s why our vision is to become the most admired public health system in the nation, so we can influence others to follow the good works we’ve done.”32
It was that vision, and his long list of accomplishments, that drew more employees to—or back to—MetroHealth.
“When Dr. Boutros arrived, it appeared early on that things were going to be different,” said Richard Blinkhorn, MD, who left MetroHealth in 2004, returned in 2019, and serves as Chair of the Department of Medicine.
“It became clear that this was a renaissance. And I wanted to be a part of this. This was getting back to who we were. Back to a sense of pride in who we were as physicians and that MetroHealth was not to be considered second rate to anyone.”33
In November 2021, Dr. Boutros announced he would step down at the end of 2022.
“I never knew what a life’s calling is, until I came to MetroHealth,” he said then. A few months later, in an interview for the health system’s archives, he explained how he felt as he prepared to leave.34
“I believe in this organization,” he said. “I believe in the people who work here. There’s nothing they can’t do, literally nothing they can’t do. They are the most capable, courageous, supportive, loving folks I’ve ever had the privilege of working with. . . .
“The frontline staff are so extraordinary. They supported and encouraged me. They are patient, kind, and committed. They have shown me how to love at work,” he said, as he finished the interview. “I pray that the next CEO gets to feel that from Day 1.”
“I never knew what a life’s calling is, until I came to MetroHealth.”
