Tom Mihaljevic on why personalization and standardization are not opposites

What this conversation is about

Tom Mihaljevic was CEO and President of Cleveland Clinic when he joined Glenn Llopis for a Forbes series on how health systems lead a changing population. Glenn opened with the tension he sees in every industry: an age of standardization running into an age of personalization, and leaders who have to serve both at once.

Mihaljevic is a cardiac surgeon and a Croatian immigrant who spent six and a half years helping build Cleveland Clinic Abu Dhabi, where he was CEO for the last three. He treats culture as the thing that makes every other decision possible, and he answers the standardization question without flinching.

Part of this conversation appeared in Glenn’s Forbes series: Healthcare in the Age of Personalization, Part 4: Where Does It Fit With Population Health? (March 31, 2019).

Personalization and standardization are not opposites

Most health system leaders describe the two as a trade-off. Mihaljevic refuses the framing:

"one is the personalization, and the other one is standardization, and they are not mutually exclusive." — Tom Mihaljevic

He draws the line by asking what a process is for. Everything patient facing and specific to an individual patient has to be individualized, and he expects that to grow as we learn more about genomic makeup, social circumstances, race and gender. The processes that are agnostic of the individual patient, such as drug prescribing and the work of the operating room, have to be standardized, because that is what keeps care predictable, accessible and less costly. Glenn pushed the point one step further:

"You need to evolve to a point where personalization helps you redefine standardization." — Glenn Llopis

A model that predates the language

Value-based care is not a transformation story at Cleveland Clinic, Mihaljevic says, because the organization was built that way. Caregivers are salaried, on one-year contracts, with no tenure, and the team has been the unit of care since 1921. The founders wanted to remove obstacles to the best possible care and refused to confuse the incentives of a provider with the needs of a patient. He prefers plainer words than value: comprehensive, coordinated, accessible care.

What delivers that care, in his account, is never a lone expert:

"Only as a team can contemporary healthcare workers meet the diverse needs, and ever changing needs, of the communities that they serve. If they try to do that as individuals they will find to be overwhelmed, burnt out, and inept, and frustrated." — Tom Mihaljevic

Read him carefully here. He is deliberately emphasizing the caregiver community over the individual provider, because no single clinician can resonate with every patient who comes before them. The individuality he is protecting is the patient’s, and the team is how it gets served.

Culture is taught, not announced

Glenn asked what he would say to peers whose systems were built so tightly around standardization that they never left room for personalization. Mihaljevic gave three steps. First, accept that culture is a learning process that cannot be mandated, and teach it. Typical onboarding in healthcare is a half day of paperwork, a badge and a medical record introduction; Cleveland Clinic spends far longer on values, on how conflict gets resolved, and on how decisions are made. Second, hire a workforce that reflects the people it serves. Third, build a structure that puts the community of providers around the community of patients.

Abu Dhabi tested all three. Building a hospital far from Ohio with caregivers from all over the world taught him something he still calls the most inspirational part of that tenure:

"Cleveland Clinic values ... can be taught, secondly, is warmly embraced by every culture, every race." — Tom Mihaljevic

Competency, he says, is table stakes in hiring. Cultural fit is the ticket in. And ownership is not reserved for the executive floor:

"the success of this organization depends upon the ability of every caregiver to think and act like a CEO." — Tom Mihaljevic

Thinking like a CEO turns out to be simple. He looks at every problem in the organization through one lens:

"we treat our patients and our caregivers as our family, and our organization as our home." — Tom Mihaljevic

Designed with patients, not for them

Glenn put his own scorecard on the table: on a scale of one to five, he rates the industry about a 2.5 at gathering feedback from patients and families, and about a one at operationalizing it. Mihaljevic agreed, then answered with mechanics rather than intentions. An office of patient experience and a chief experience officer. Ombudsman services. Patient and community advisory councils that feed directly into how care is delivered. A large office of spiritual care. Patient navigators for people moving between many providers. The way children are cared for in intensive care was reshaped by the families who had been through it.

Then there is the building itself. Cleveland Clinic runs a design office, and patients take an active part in its work:

"you would find a space that is not designed by us for our patients, it is designed with our patients, and us, for them." — Tom Mihaljevic

Late in the conversation Glenn described the immigrant perspective on leadership he wrote about in 2009. Mihaljevic picked it up without hesitation. He joined Cleveland Clinic because of the selflessness he saw in it, and he came to the country for a reason he states plainly:

"came to the United States because of the idea of the United States, for no other reason" — Tom Mihaljevic

That is why the conversation never stays inside diversity and inclusion as a program. For Mihaljevic, serving the individual patient is simply what the work is, and culture is how an enterprise keeps its promise to do it.