Chapter 05: A New Hospital; Resources and Growth; Creating Multi-Disciplinary Diseae-Site Clinics; Divisional Strategic Planning

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Chapter 05: A New Hospital; Resources and Growth; Creating Multi-Disciplinary Diseae-Site Clinics; Divisional Strategic Planning

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Description

Drs. Sawaya and Balch begin this chapter by talking about opportunities that opened up for surgery when the Alkek Hospital was being build. Dr. Sawaya talks about the new operating suites (in comparison to the older one). The discussion then turns to the renovation of the Clinical Research Building. Dr. Balch then observes that when he became Vice President of Hospitals and Clinics, he was in a position to reorganize delivery of care around disease-site clinics. He explains that the culture allowed it and there was little controversy. Dr. Sawaya confirms that the specialties worked well together, siting the fact that all faculty are salaried. He talks about research that the collaboration allowed. Dr. Balch then talks about how he used divisional strategic planning as a tool to build interdepartmental inclusion and connection. Dr. Sawaya observes that departments were also given autonomy in this system. They discuss the value of the division organization in competing for institutional resources.

Identifier

SawayaR_01_20190312_C05

Publication Date

3-12-2019

Publisher

The Historical Resources Center, The Research Medical Library, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

Building the Institution; Leadership; On Leadership; Institutional Politics; Understanding the Institution; Growth and/or Change; Research; The Business of MD Anderson; The Institution and Finances

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History | Surgery

Transcript

Charles Balch, MD

So, let’s go back a second. As you know, in 1993, Mickey [LeMaistre; oral history interview] deputized me to be the vice president for hospitals, and then after that I was the first executive vice president for health affairs, but I brought a support for the surgical specialties as part of that role. Remember what we did was we built a new hospital, with new operating rooms, because you can’t retrofit all this fancy equipment in existing places. For example, just such things as the transition floor is usually about three feet in most typical buildings, including the building where our operating room is. In the new hospital, the transition zone for installing infrastructure, wiring and so forth, that drop down in the ceiling, was a half a floor. Nobody had ever done that before, because we knew that we were going to have to innovate and keep adding things, and you couldn’t break through the ceiling to do that. You had to had an interstitial floor above the operating room.

Raymond Sawaya, MD

This is absolutely critical, what Charles just said, and to add to it—

Charles Balch, MD

There was a surgeon also making sure that we looked after that.

Raymond Sawaya, MD

I remember. I was new here and I said my God --I would look at our operating rooms, I would say this is MD Anderson, what kind of operating room do we have? The ceiling was low, the color of the wall and the floor was … Over years it kind of washed out. It wasn’t attractive at all, and in fact, we had the feeling that it was dirty. We couldn’t clean it, and so what you said is so absolutely true: that that became an extremely high priority, but you have to be a surgeon to really be able to see that. Having the ORs that we have now in the Alkek Building, is just phenomenal. And so that robotic microscope I told you of, I couldn’t install it in the old OR. You can’t you know? So I had to wait for the year 2000, when the new building opened the ORs and all of this, to install it and so on.

Charles Balch, MD

The other thing that we did when I was at that level, was to build an entire building, which we called the Clinical Research Building. That was dedicated to laboratory research for the clinical departments. An entire building. And that was kind of revolutionary too, because most people said the traditional lab space should be among the basic scientists, and the surgeons would get a little piece here and there, scattered around. So that was a really important concept. The third area was the clinic areas. When I was VP, and this was because of the genius of Donna Sollenberge [oral history interview]r, I could state strategically, we want to do this, but Donna Sollenberger was the person who really made it happen, first for the Division of Surgery, when she was there. But then when she went with me, at the hospital and clinics. We totally reorganized the clinics into disease site clinics, and the importance of that --that had not been done anywhere in the country. We were the first. Now people are doing it and they’re publishing: oh, look at how this has changed our research and our clinical and our referral practice, and I’m thinking we did this 20 years ago. But it was also because the culture allowed that to happen, you know? We didn’t have to force it, but we had to create the resources and the facilities to allow that to happen.

Raymond Sawaya, MD

Yes. Yes.

Charles Balch, MD

The other thing that was important, and I remember this impacted you as well --and this was the strategy of Mickey LeMaistre-- was the Rotary House. For a long time there was a bridge across Holcombe Avenue that went nowhere, and it was because Mickey had some leftover money and he built the bridge, but it didn’t go anywhere on either side. He said oh, that’s my future vision. And so finally, we put a clinic on the one end of that, and a hotel on the other end. I remember when the Rotary House started, the average length of stay for the hospital went down an entire day. Part of that, I remember you had some patients you couldn’t send out to another city after brain surgery, but you could send them across the street to the hotel, with their family. So this is part of the delivery system, really --was something that again, was innovative. Other than the Mayo Clinic and the Cleveland Clinic, there were no hotels attached to a medical center.

Raymond Sawaya, MD

I want to bring back one aspect that somehow I hope will fit in the big picture, and that speaks about MD Anderson, but also about us surgeons and other specialties working together in a productive way. Charles mentioned salary before. The point I want to emphasize is the fact that we are all salaried. Full-time salaried at MD Anderson. Yes there is some difference in level of compensation just because of the American Association of Medical Colleges, that recognizes the lengths of training, how many years, the complexity of the work with it, that’s why there are differences in how much one is paid. Beyond that, the fact that we are all salaried, I think is crucial, because—and I will give you as an example. A study that we led in neurosurgery, where we compared brain metastases, treatment between surgery and radiosurgery. Radiosurgery, we don’t cut on the patient, it’s a focused beam of radiation, like a gamma knife --you may have heard that term. Well, surgery, the surgeon does the operation. So if we as individual faculty were compensated based on how many operations I do in the operating room, then I want to operate on everybody that walks in my office, right? The same thing with radiation doctors. Where because we’re all salaried, we agree that we can randomize patients between surgery and radiosurgery, patients who qualify for either treatment. We conducted a study like this, as many, many other studies have been conducted by other departments. But that’s an example where being all salaried, as surgeons, radiation doctors, medical oncologists, facilitates to say what is the best treatment for that patient. It could be surgical and, good, let’s prove it and let’s move on. But it could be not surgical. You know it depends on what the matter is, what the problem is. So I think it’s important to emphasize that.

Charles Balch, MD

Let me add one other thing that I think has been essential to our success. And again, this gets back to Mickey LeMaistre, who embraced the concept of using the strategic plan as a mechanism to gain the consensus building, to get everybody’s ownership, so that people at different levels could feel like it’s not just a top-down thing, but that they have put into the strategic plan. We are today, in 2019, in the midst of strategic planning, and even the employees are asked to contribute to the strategic plan. I can tell you when I came, there wasn’t an institutional strategic plan in any other place that I knew, and certainly it was something that Mickey embraced, but he didn’t have that piece, because nobody in Surgery embraced that concept. We had a department strategic plan, a division strategic plan, that went up into the vide presidential level, but it also I think enabled and ownership, that this wasn’t just Mickey LeMaistre’s strategic plan. It was one that had a lot of discussion and consensus building. I’ll get back to the collective wisdom of not only what are your strategies, but what are the resources and the priorities necessary to do that. I think one reason the institution and that each layer succeeded is because of the culture of planning, of consensus building, and using the strategic planning mechanism as a way of one, creating their priorities and things, but then once you have the plan everybody knows what it is. It’s not just something that a few people hold but it’s published. You know what it is, and then the budget has to follow that strategic plan.

Tacey A. Rosolowski, PhD

You know as you’re speaking, I’m remembering my conversation with Donna Sollenberger, and I think she has quite a long section in her interview about assisting you in creating the divisional relationships. She talks in some real practical terms, about this process of it creating buy-in and transparency and trust.

Charles Balch, MD

Part of it was we had to delineate what’s the difference between the department and the division, and you have to have a written document that delineates that. But I also felt that it was equally important for Ray and the other department chairs, to have a major role in the division’s strategic plan. So this wasn’t me saying this is what you should do, or this is the core facilities.

Raymond Sawaya, MD

I agree. That’s what I was saying earlier, as I can only speak for the Division of Surgery.

Charles Balch, MD

I think it was a democratic system more or less. Not everybody agreed with that, but at some point in time you had to make some lonely decisions.

Raymond Sawaya, MD

Well you had to prioritize because resources are limited.

Charles Balch, MD

Everybody could say they had input and they knew what the decisions were and were there early on.

Raymond Sawaya, MD

No question about it, and I said it earlier, that I think within the Division of Surgery, we have been fortunate for my entire stay at MD Anderson, to have had sufficient autonomy to really impact the direction and growth of my department. I’ll state that very strongly and again, comparing with other divisions, I think we were very fortunate to have had that culture and for that culture to have survived all these years.

Charles Balch, MD

So Ray in the final moments, let me talk about the division with you, because we take these for granted now, but they were new. We had information technology and a dedicated person to make sure that the basic information systems were available, that you couldn’t put together on your own at the department level and couldn’t interface with the institutional one.

Raymond Sawaya, MD

Yes.

Charles Balch, MD

We had administrative cores, we had libraries, we had core facilities in the laboratory, we had clinical research infrastructure. So how did those, can you recall those kind of things that the division provided for the department, that you might not otherwise have been able to access at the institutional level.

Raymond Sawaya, MD

Oh, absolutely. To this day, IT … I mean we argue strongly, because you know on and off—

Charles Balch, MD

There was no information systems when I came.

Raymond Sawaya, MD

They wanted, you know … Because they want to cut budget and so on, they wanted to pull the IT people, the information technology people that in our case, we have in the Division of Surgery. You know if you go online and try and get somebody in this whatever central office they have, we’ve got our own person who knows us in the division. And actually, we have more than one person. Danita now is the head person and there are two or three people working with her, and the response … I mean my secretary calls Victor in the morning and within an hour, Victor is in my office looking at what problem I have with my computer. I don’t know or remember the history behind starting this but it sounds like you have made that happen.

Charles Balch, MD

No that was new, it did not exist. The administrative and budgeting process of having...

Raymond Sawaya, MD

And the research.

Charles Balch, MD

And part of this was equity across the departments, because before it was who could speak the loudest and twist people’s arms to get resources. But now everybody—there was one person who managed the budget at the division and everybody saw the budget.

Raymond Sawaya, MD

There were some old timers who had been here a long time.

Charles Balch, MD

Who did not like the sunshine.

Raymond Sawaya, MD

No, but they had their own connection, their own way of doing things, and so yeah, having that as a core resource, obviously is important. The research, you mentioned the core for research. You know, you want to get a cell sorter or some of these more expensive laboratory machines, we’re talking about $200-$300,000. Well me as a department, it’s hard to compete, for instance with a basic science department, but we had a core facility for surgery. Now you’re talking about dozens of researchers, either physician scientists or laboratory scientists, who will use that piece of equipment. So now when we go through the Division of Surgery, our core, research core, and ask during the capital equipment negotiations, we are now competing with other entities, well we have bigger stature.

Charles Balch, MD

This is very important because in competing for institutional resources, when a department chair goes and competes with Irv Krakoff, who has 17 departments, you’re not going to have the same political clout to acquire the resources.

Raymond Sawaya, MD

Exactly.

Charles Balch, MD

Then if one person is representing all of the surgical specialties in competing for the resources, to make sure there’s equity in the allocation of institutional resources, that go to the Surgery Department, including for surgical research. And then you know, I think we’re over time.

Tacey A. Rosolowski, PhD

No, no, we’re good, we’re still good.

Chapter 05: A New Hospital; Resources and Growth; Creating Multi-Disciplinary Diseae-Site Clinics; Divisional Strategic Planning

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