The Cleveland Clinic: Clarity, Focus, and Simplicity

In 2004, soon after Toby Cosgrove became CEO of the Cleveland Clinic, he saw the writing on the wall. Despite being one of the premier medical institutions in the world, the health of its employee population mirrored the same chronic disease, stress, and bad habit patterns of their city and nation. If that continued to rise, they projected that, by 2016, the cost of health care for their 40,000 employees and 41,000 dependents would increase by $400 million.

Cosgrove knew that if the Cleveland Clinic was also going to fulfill its mission, it would have to set an example. He hired Dr. Michael Roizen in 2007 as the first chief wellness officer—the first CWO for the Cleveland Clinic and first in the United States. The teamwork of Cosgrove and Roizen formed three key elements that have led to the Cleveland Clinic's success:

1. Clear, resolute, engaged leadership
2. A focus on five normal outcomes for employees
3. A comprehensive six-element push for culture change

Dr. Roizen explained the five normal: “If our employees hit five ‘normals,’ plus get their immunizations up to date, they get back to the 2009 insurance rates when we started the program. That is, essentially, a savings of 30% and for some, that means zero out of pocket cost.” These five normals have recently been expanded to 6+2. Those normals are:

1. Blood pressure less than 130 over 85
2. LDL cholesterol levels under 100, 100 with no diabetes and no coronary artery disease, less than 70 with
3. A waist measurement of less than one-half the height or Body Mass Index less than 29.9
4. Blood sugar under 100
5. Zero nicotine as monitored by a cotinine level less than obtained by secondhand smoke
6. Stress management program completed
7. Fasting Blood Sugar or Hemoglobin A1C less than 107 or less than 6.3%
8. See a primary care provider yearly and immunizations up-to-date

In other words, they simplified and narrowed the focus: a dashboard of eight simple measurements. After all, if you're achieving the first five, you're most likely doing everything else right too.

They also knew their campaign to bring radical change must be just as simple and clear. So they also narrowed and simplified that focus into six principles for change:

1. Make culture a priority: “Toby continually messaged how important being healthy is to the energy you bring to work, to your overall well-being, and to your ability to live well. You don't want to live with a disability. Every month, he rewarded someone who has reduced stress, lost weight, or quit tobacco.”
2. Make Room for “Aha” Moments: “Aha moments are the sudden knowledge, like ‘If that person can do it, I can do it too!’”
3. Provide options: “We found Weight Watchers worked for some people, a gym membership was preferred by others, e-coaching by our own program for many, and nutrition classes were key for other people. Providing options brings more people into the program. If you offer one program, maybe 20% will succeed; but if you offer 10 options, we've found over 70% can succeed, even to lose weight to get to a non-sickening BMI.”
4. Knock down barriers; reduce constraints: “You have to knock down barriers and make it free. We used to reimburse the cost for smoking cessation treatments 83%–89% after the employee quit smoking. The day we made the first dollar free, we had four times as many people sign up that day as had signed up in four years.”
5. Nudge people to make the healthy choice: “Make healthy choices the easiest. You can't buy a fried piece of anything on the Cleveland Clinic campus because we took out all the fryers. You can't buy a sugared drink on the Cleveland Clinic campus. You can have a Coke, but you have to bring it in. If you're going to get sick, you have to make an effort to get sick. We want to help you stay healthy.”
6. Incentivize in a big way: “We incented in a huge way, so more than half of Cleveland Clinic employees are still paying the insurance rates they paid in 2009. We also let people add a buddy, a social nudge, for all kind of things, for hypertension, etc., because being socially responsible and accountable to someone else (a coach, even an electronic e-coach, or telephonic or video coach) is a key component.”

Whereas 6% of Cleveland Clinic employees had 5 normals in 2008, over 40% now do; whereas 12% with chronic disease participated in a chronic disease management program in 2008, now over 63% do (if you decrease the influx of chronic disease, medical care costs less and people bring more energy to everything they do). Unexpected absenteeism has decreased from 1.07% of days to 0.70 %. The clinics employees have also earned a boatload in incentive and costs saved. The Clinic saved over 254 million (all in medical costs including incentives and wellness program and administrative costs) according to its once very skeptical CFO in the last three years for its now 101,000 employees and dependents compared to where it would have had costs by 2017 if it had averaged the health costs of the rest of private hospital employers in the USA. And savings get bigger yearly. Cleveland Clinic estimates it will save over $150 million more this year—you see as employees and dependents get healthy, they progressively save more dollars.

In our study of companies and other organizations for this book, we saw that each approached employee health and well-being differently. But we also saw that the best all had two things in common: clarity and focus. The Cleveland Clinic sets a high bar of expectations.

Barry-Wehmiller: “We Just Need to Care”

From its humble beginning in 1885, today Barry-Wehmiller is a St. Louis–based $3 billion global enterprise of more than 12,000 employees. Their primary business, supplying manufacturing technology and services, evolved from their roots as manufacturers of pasteurizing equipment. But the real business is acquiring and transforming struggling companies. B-W first caught my attention when I learned of their more than 100 acquisitions. When 70–90% of mergers or acquisitions fail, Barry-Wehmiller surely knows something most don't.¹

Bob Chapman, the slender, energetic, constantly moving CEO for Barry-Wehmiller, carries a consistent message to every mile and every moment of his life: “Everybody matters” is not only the title of his best-selling book,² but it describes his life and passion. Solid life lessons, including some near-death business experiences, formed that message.

I reached out to Bob because I loved the book's story and philosophy. It confirmed the MindShift message. Upon my arrival at B-W, Rhonda Spencer, the chief people officer, built the onramp for my day with Ed Strouth, B-W's director of health and well-being, Laurie Ferrendelli, director of organizational development, and Bob Chapman.

The B-W story began, as it did with many companies, with a focus on health costs in the 1980s. From that, the company continued to push the boundaries until a culture of care began to emerge in 2003. Because the company grew so rapidly, so did the health and wellness needs of the employee population. B-W faced that growing need by making a new commitment to “everybody matters.” To make sure leadership matched the commitment, they made Rhonda the chief people officer in 2014.

Barry-Wehmiller aligns with several of the principles described in the Cleveland Clinic Way: aligned culture, aha moments, options, knocking down barriers, and large incentives. They are also exploring and expanding healthy nudges. Four years into this wellness strategy, they are making progress like that of the Cleveland Clinic. That progress comes despite B-W's great differences from the clinic: they are spread across the globe, their US factories are often located in small industrial towns, and they have a much older population.

When Laurie Ferrendelli first took the director of organizational development position, she told Bob she understood B-W's focus on employee care, “If you take care of employees they take care of clients, and that results in taking care of business.” But Bob said, “Perhaps—but that's not why we do it. We take care of people because that is the right thing to do. I expect our leaders to run the business to support that.” He went on to say, “I do expect that we'll serve our clients better, but that is a by-product. It is not why we do it.”

When Laurie first entered the world of wellness, she quickly learned, “that a lot of vendors were selling this as another way to manipulate your employees for your gain. And if you start from that place, you're never going to really help people. We approach wellness from the standpoint of a fundamental value for people who are touched by our organization. We do it because we want people who have healthy lives. Companies that do it for any other reason have no chance.”

After my time with Bob and his senior leadership, I asked him, “Bob, what happens when you're not here anymore? How do you scale this?”

He's a straight shooter: “We've been working on that question for 12 years. It started when someone asked, “‘What's your greatest fear?”’ My greatest fear was that we would build something great and find it to be too dependent on me. So, I kept thinking, Okay, what are we going to do about it? And I realized what great religions do over time. They articulate their beliefs. They tell stories that affirm their beliefs through disciples who pass it on. So I wondered, how are we going to create disciples?

And then he found the answer; he realized "We got to create a university. We got to teach people. We decided that day to start a university. We had to do it ourselves because our education system makes managers, not leaders. The beauty is we started with a clean sheet of paper. We said, “‘How do we teach people to care?”’ It starts with listening skills, thinking like a leader, inspiring like a leader, acting like a leader.

“Now we offer this to senior executives from around the world. We didn't have any idea that we had been blessed with an idea that could change the world, but there's no question now, given where we are in the journey, that we have been given an idea that could begin to heal the brokenness that we're feeling in this world. We don't need taxes or politicians to fix our problems. We just need to care.

“As far as our mission for affecting others outside our company? We're giving people an appetite, we're not feeding them. Simon Sinek calls it the law of early adopters. We need to find people who believe what we believe. We're not trying to change what they believe.”

Tom Emerick: The Human Touch

Tom Emerick ran the benefits program for Walmart's 1.3 million employees for more than 11 years. Before that he handled BP's 220 benefit plans. But, before all that, Tom started as an actuary. So he knows the numbers, what works and what doesn't. His years with Walmart and BP gave him a ringside seat for watching how the 10% of employees with complex chronic conditions often fall through the cracks of proper care. That results in tragic health outcomes and drives 80% of corporate health-care costs.

While wellness programs are focused and incentivized on the 90% of relatively healthy employees, providing quality care for the chronically ill brings a human touch to those who struggle daily.

Tom talks like a country doctor or pastor: “Folks in this outlier group have very serious conditions. Many of them are seeing multiple specialists, and they're being given multiple prescriptions, and there is gross variation in how patients like that are handled from tertiary center to tertiary center. There is also gross variation in quality, net cost, and even in the medical ethics for this population of patients. 20% receive bad diagnoses, 40% receive bad treatment plans. The cost impact can be more than 400% of what proper diagnosis and treatment would deliver.”

Tom can burn hot when he talks about an American medical system happy to overdiagnose and overtreat patients. He held up a Wall Street Journal article that revealed coronary artery bypass grafts, given to patients with stable angina, offer no advantage regarding longevity or lifestyle for 97% of those patients. He pointed out:

In the US, we have 1% more heart attacks than in the UK. We do 350% more invasive procedures, and the British survive heart attacks longer. There's just simply no excuse for it. People say, “But we're less healthy.” Come on; we have 10% more obese people than the UK, not 350%.

Tom recommends that we first educate ourselves on the vast range of quality and costs. Barry-Wehmiller was stunned at the differences when they began to use Compass as a health concierge. When an employee needed hip surgery, Compass learned that his doctor worked in three hospitals and the cost difference between the hospitals was as much as $12,000. Over the course of Tom's 28-year career, he helped hundreds of employees needing acute care. He found that sending them to the Mayo or Cleveland Clinic improved the accuracy of diagnosis but also provided long-term care and support.

He speaks persuasively from his depth of experience: “People are going to get sick, but the first thing we should ensure is that they receive the right diagnosis. If we're running benefit programs and we're letting 20% or 30% of the bucks get spent for people that have the wrong diagnosis, we can't say we have a wellness program.

“One specialist is looking at a blocked artery, another is looking at arthritis, another one is looking at a bad hip. Very few places look at the whole person. We can fix that. We need a new definition of medical ethics: Let's determine the desired patient outcome and use the safest, least invasive way to get there. That eliminates 60% of the heart surgeries in America.

“Only 5% of medical facilities practice this new form of ethical medicine. The Mayo Clinic, Cleveland Clinic, and Intermountain Medical Center in Utah are among the best. You know one thing they all have in common? Doctors are salaried. They don't get paid extra to cut. We talked a lot about wellness incentives. People behave the way they are incentivized to behave. If a doctor can make $3,000 or $4,000 for two hours' work in an operating room, why not? It's pretty easy to make that blocked artery look pretty severe.

“Lowe's set up a program to send their heart cases to the Cleveland Clinic, and they're having smashing success with it. The best care is the most cost-effective. How cost-effective can it be to do surgery on somebody that doesn't need it? What should HR people look for? The highest ethical standards, best outcomes, and lowest net cost. In other words, they want Centers of Excellence.

“The cost of health care is doubling in 10 years. The folks running corporate benefit plans are the only ones in America that can stop this. You can absolutely call a complete halt to this for 80% of your claim dollars.”

Ron Goetzel: 10 Principles

Ron Goetzel, the senior scientist at Johns Hopkins Bloomberg School of Public Health, vice president of IBM's Watson, and health and board chair for HERO, is a data guy at heart. He is probably more responsible than any other person for pushing the industry toward tighter standards of program effectiveness.

When I asked Ron what it takes to implement an effective wellness program, he outlined 10 criteria. He began by stating that there is no one-size-fits-all and that a variety of strategies and activities are needed. Here's his list of 10 criteria, including his comments about each:

1. Culture of health: “Wellness efforts have to go beyond a program. It's a way of being. Bob Chapman (Barry-Wehmiller CEO) has a good approach. The qualities of that culture include care for one another, and support; it's not a dog-eat-dog environment. Look at the positive culture of Chevron. The cultural imperative is supported by the environment, it's part of their strategic planning. The plan is tied to performance metrics for managers, and even the line workers.”
2. Leadership commitment: “None of these programs really work unless you have an engaged C-suite. They have to demonstrate that employee health and well-being is what they believe in. ‘It is who we are as a company, what we do, what we practice.’ They must lead by example so it permeates down to middle managers and supervisors. It cannot be a once-a-year message from the CEO. It's day-to-day operations of supervisors, and it manifests itself in all kinds of ways, including work/life balance, flexibility, stress, and decision latitude. All of these really do matter in terms of creating a healthy workplace. If the program is not properly resourced, it won't work. There has to be a budget commitment that includes a say from workers and union in the design of the programs.”
3. Specific goals and expectations: “Like any other business idea, you can't just say, ‘We're going to get people to lose weight and exercise and eat healthy.’ What exactly do you mean? How much weight loss are we aiming for? How much exercise? How much and what kind of nutrition goals? How exactly are you going to figure this stuff out? What's the short-term goal? What's the long-term goal? Three, five, 10 years from now? Do you stick by those goals or let them fade when it becomes hard work? Are they measurable?”
4. Strategic communication: “It's like selling anything, any product. How many wellness champions do you have? The more you have the more likely you're going to get engagement. If I share an office with you, and you tell me, ‘We're having a fun walk,’ or, ‘We're going to have a healthy lunch; come join us,’ that's much more compelling than an e-mail from HR. The reason companies are successful is because they keep selling it, with variations on a theme, with humor, with a compelling narrative, you name it. It's marketing and communication. You've got to sell health just like you sell everything else. So, it's got to be consistent, constant, engaging, targeted, and often times direct person-to-person selling. That means you've got wellness champions scattered throughout the organization.”
5. Employee engagement by design and disciplined implementation: “Here's the real story of most wellness programs: The vendors are selling to the HR benefits people, and that is who they view as their customer. They say, ‘We're going to save you money. We're going to produce some ROI. We're going to lower absenteeism and disability, workers comp.’ But they never really think carefully about the employee as the real customer. The vendors need to be asked, ‘How are you selling it to the worker? Why should they be involved in any of these programs? What's their ROI for participating? How is your offering compelling to my employee base?’

   “One vendor promoted meditation and yoga for employees, the company bought it, and nobody showed up. That's because everybody, young people, wanted to do aerobics, and they want to be climbing walls, and they wanted to do stuff on bicycles and all that. Nobody bothered to ask them, ‘What would you like?’ If the employees are not involved in designing the program; no focus groups, no surveys, and no ongoing feedback about what works and what doesn't, it ends up with good intentions that no one really cares about.”

6. Follow best practices: “If I want you to quit smoking, giving you a brochure that tells you that you're going to die of cancer is actually not very convincing. However, something called motivational interviewing may be able to slowly, gradually get you to think about quitting smoking. There are different ways of doing that, those kinds of behavioral interventions, choice architecture.”
7. Effective screening and triage: “You need to have ongoing annual assessments of people's behavior and risk factors. Now, does that mean biometric screening? No. The biometric screening part should follow the US Preventive Services Task Force [PSTF] guidelines. Some employers do too much screening, and they screen for stuff that shouldn't be screened. The PSTF people do systemic reviews of the evidence and say, ‘Well, this is how often you need to have your blood pressure, cholesterol checked, glucose and weight checked.’ They also provide guidelines for checking tobacco, alcohol abuse, and depression. An important part of the assessment is triaging people into high and low risk, with more attention being paid to the high-risk people, and more of an outreach to that population.”
8. Incentives: “Let's talk about smart incentives. They engage you, convince you to participate in programs. There are lots of ways to do it, anywhere from having lunch (or a walk) with the CEO, to a plaque you can put on the wall, articles in the company newspaper about you, and of course dollars. But I don't believe dollars is the best way to get people to change behavior. It's very effective to get people to show up for something, but I can't give you enough money to get you to quit smoking, eat healthy, exercise on a daily basis, and manage your stress. I really can't. Anybody who thinks otherwise is a fool.”
9. Effective implementation: “You may have the most beautiful plan, wonderful brochures, lots of money and budget, and it is not working because people don't trust you or they are not integrated into the culture. It's being offered by a vendor. It's not flexible. It's not fun. It's not fresh. It's not interesting. This is a challenge, to get something that's a good idea and actually put it into place within your culture. This is the ecosystem.”
10. Measurement and evaluation: “You can have fulfilled all the other nine things, but you have zero data to show that it's made a difference in anything. You need to set aside a budget for measurement and evaluation that looks at multiple dimensions of the program. For a small company, it can be as simple as an annual survey of your workers, asking them, ‘What do you think?’ Or, it could be a very extensive program evaluation done by people like myself and my team, using insurance claims and other data, financial analysis, to figure out whether the program is actually working or not.”

J&J: Persistence, Data, and Continual Improvement

Johnson & Johnson is a 130-year-old company with about 130,000 employees. They are a lead supplier of medical equipment, pharmaceuticals, and everyone's favorite, Johnson & Johnson's baby shampoo. J&J is also held up as an exemplar for their corporate wellness program. Even the wellness skeptics like Soeren Mattke and Al Lewis admire J&J.

Dr. Mark Cunningham-Hill was their head of occupational medicine and global health services for 7 years. Although Mark recently left J&J to start his own consulting firm, he gave me an in-depth, behind-the-curtain look at J&J's wellness efforts.

As Mark told me: “My team designed the strategy around health, wellness, and mental well-being. A lot of our work considered the role flexible workplaces played in shifting culture and improving health by allowing employees to be more effective, focused, and energized.

“J&J has always been on the cutting edge of wellness efforts, building on traditional HRA (health reimbursement arrangement) wellness programs with fitness programs and fitness centers…very traditional stuff. Gradually, over the last five years, we've started to move into other areas. There's enough good data at J&J to know what the big issues are, and J&J focuses on them: movement, eating, mental health, and the quality of the workplace, both from an occupational safety point of view, but also from how the workplace drove and supported our focal behaviors.

“Alex Gorsky, CEO, is a great leader. He's the champion of these values. Every time he speaks, he promises more around health and wellness and the importance of it to the organization. He used to tell stories about his life, how he suddenly realized how important his family was to him and what he does, to focus on them. I think that kind of leadership, the storytelling can be really powerful.

“J&J's history of data has produced metrics that really work. Managers can track change over time and hold individual senior leaders accountable. The next five-year goals will be a big step forward. Data will continue to drive the future. Our ability to measure a change allows J&J to build and expand its support and culture of health. The ability to connect the dots through data gives J&J a unique advantage. Many companies express aspirations to provide a healthy workplace but can't connect performance to their values.

“J&J is known to provide a quality work environment on par with Google and Apple. But they deliver that quality to a much broader diversity of employees. That's why J&J's success in delivering a culture of health is sought out by companies around the world.”

Mark acknowledges that ROI is an important piece of the conversation, but emphasizes it is just that, a piece. For Mark, it gets back to a deeper question: “Are these efforts simply about return on value? If so, what is that value? Is it workplace experience, workplace culture, retention, attraction, or employee engagement? We know engagement leads to productivity. J&J is taking 100,000 employees through the corporate athlete program, designed for top executives by professional sports experts and Navy SEAL trainers. The program teaches employees how to live better, not just perform at a higher level.

“By the time I left in April 2017, we'd taken 54,000 through the program. We analyzed the people who had been through it and compared performance to those who hadn't been through the course. We looked at performance ratings, retention, and promotion. There were statistically significant correlations of superior performance from those who went through the program.

“The cost of the program for 100,000 employees globally is probably about $40 million. There is between a $200 million and $400 million return on that. But we didn't do this as an ROI. It was really about learning and seeing if the corporate athlete program has a real and measurable impact on the quality of lives and performance at work.”

Mark told me that J&J stopped chasing after HRAs at the end of 2015, when they reached their goal of 80% global participation. That program never convinced J&J they got that much value. It just told them what they already knew, that high-risk employees were high risk. The people who were obese, smoked, or sedentary were unhealthy.

I asked Mark how J&J communicates a consistent and engaging message across the three families of companies and all of the sub-business units. He told me, “Perhaps that's where it gets back to the building; how to connect the dots for people, so they understand our program around employee flexibility, financial health, physical health, and understanding health-care benefits? Creating posters, sending out fliers or updates isn't enough. J&J has begun to look at the workplace as a way to tie together both the services and the messaging.

“We are using design nudges to encourage movement, especially in locations that are not typically thought to be places that embrace wellness. One of our facilities in Juarez has 3,000 employees in one manufacturing location. We provided walking paths and encouraged people to walk together more. We also developed an inviting staircase design to nudge people to use the staircases. We've used lots of little nudging tricks about how to get people moving that are successful.”

I found that J&J's big lessons are consistent with other highly successful cultures; they begin with leadership conviction and commitment. In terms of making the strategy work, J&J's integration of HR, wellness, facilities, and IT, along with metrics tied to business outcomes, provide the ability to learn, adjust, and improve.

The Effective Leader

Each of the conversations in this chapter delivered solid, tested, and very real lessons in effective leadership to me. I heard the constant theme of picking the few priorities that will make the big differences, focus your time and attention to reinforce those priorities, resource the hell out of them, be that mission's first learning officer, and stay real.

No one ever said it better than Peter Drucker:

Management books usually deal with managing other people. The subject of this book is managing oneself for effectiveness. That one can truly manage other people is by no means adequately proven. But one can always manage oneself. Indeed, executives who do not manage themselves for effectiveness cannot possibly expect to manage their associates and subordinates. Management is largely by example. Executives who do not know how to make themselves effective in their own job and work set the wrong example.³