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A Venn Diagram for Health Care Integration (09:17)

NewYork-Presbyterian, like many health care organizations across the U.S., is involved in integration. But consolidation isn’t about “getting bigger just to be big,” says Laura Forese, NewYork-Presbyterian’s Executive Vice President and Chief Operating Officer. It’s about what you do with that consolidation. “It’s about making this system better,” she says.

First and foremost, when thinking about health care integration, we must consider the perspective of the patient. They are the consumer, and if they’re not happy, they’ll walk away. We must also consider the perspective of society, which shares characteristics with the patient.

What does the patient — and society at large — want?

  • Access. “The American consumer wants health care when he wants it and where he wants it,” says Forese.
  • Quality. “You expect to have great quality and great safety.”
  • Excellent experience. “If you’re not satisfied with that, you’re out of there.”
  • Lower cost. “We’ve got to pull some cost out of the system.”

Forese shares a simple road map for providers to follow when working through integration that keeps the perspective of the patient in mind. The road map is a Venn diagram by design — each piece is interrelated, and the center matters most.

  Click To Enlarge.


“As institutions, hospitals, physicians, whatever it is are coming together, standardization really matters,” says Forese. There are the obvious things that make administrative sense to standardize, such as having a single purchasing system, a single formulary, and a single equipment vendor. “But it’s not just about the price,” she says. “It’s efficient. You’re going to learn to do something and then you’re going to spread it. The fewer times you have to reinvent that wheel, it just makes sense.”

“You’re also going to have better quality, because when you fix something, you fix it once. And then you move that across. You find with your data who’s doing something well and then you point that out, and you get everybody to understand that they can do it better,” Forese adds. “If you’re the patient and there’s a best way to do something, well you absolutely are going to insist on that.”

Through a similar process, you can decide not to standardize certain things, as well.

“Standardizing is critically important to achieving all of those aims [of health care integration],” says Forese. “When you’re talking about how to do this better, you want to keep coming back to standardizing.”


Deciding what you do, where, can be tough in many ways, says Forese. Expanding patient access is important, but “you’re not going to do every single thing everywhere,” she says. “You can’t. It doesn’t make sense. It would be too expensive. You can’t take something like a heart transplant and think you’re going to replicate those resources. You won’t have enough business to get everybody good at it.”

What about things you’ll need a lot of, such as cardiac catheterization? “Back to my first point, you better standardize those,” says Forese. “Because if there’s one best way, the patient doesn’t care if she’s having it in one center versus another. And price will come out of the system when you replicate that over and over again.”

“You’ve got to work with your communities, you’ve got to understand them,” adds Forese. “Yes, it’s going to be about political pressures. Regionalizing is hard, but worth it. Deciding how and where you’re going to do certain things is a way to make rational sense of being a system.”


Virtualizing is about using technology to improve various aspects of health care. Access is an obvious first point — patients and doctors are increasingly Skyping and FaceTiming. “But it’s not just access,” says Forese. “It’s quality.” For example, a mobile stroke ambulance that’s out with the patient could have a scanner for the radiologist to read back at the hospital, and then instruct the paramedic to put in a clot-busting drug. “That’s just better quality than what we’ve had before. And it’s a way to expand our resources,” she says.

In another example, the U.S. doesn’t have enough psychiatrists or mental health providers, and we’re not going to suddenly have enough overnight. But we can use technology to expand our resources. “Imagine now connecting all of the right specialists, in the right way. That’s for our patients. That’s how we need to do that, and patients are comfortable with this,” says Forese. “The more we can use virtual medicine, the fewer bricks-and-mortar [facilities], and we get away from some of this capital that we can no longer afford.”

“We’ve got to be creative with it. We’ve got to do more virtual monitoring even to patients in their homes, because nobody likes to be in a hospital and it’s a better experience for them — and I would say safer, because when you’re not in a hospital, you’re not getting a hospital-acquired infection, and are much less likely to fall,” says Forese. “Every time we can use virtual medicine to keep patients out of the hospital, everybody wins.”


In the center of the Venn diagram: engagement of the people involved in health care. It’s about their hearts and minds, and the culture of the organization. “‘Culture eats strategy for lunch’ is so true,” says Forese. “It doesn’t matter how good our strategy is. If we don’t have the people buying into it, it’s not going to happen.” The “culture of respect” at NewYork-Presbyterian — and a credo that spells out that every person counts, that everyone is included and belongs — has helped them come together as an organization.

Forese stresses making a commitment to the team. “They’re the ones who have to buy into this notion of what we’re doing. They’re the ones who are going to make standardizing, regionalizing, and virtualizing possible.”

In conclusion, Forese reminds the audience that the Venn diagram she presented is a deliberately simple, practical model for health care organizations to follow as they move toward integration. “That’s really the point as we’re thinking about integration. That it’s a simple model that can work for the board room, for the surgeon, for the nurse, and maybe, most importantly, for the housekeeper. Because that’s how we’re going to pull together and make care better.”

From the NEJM Catalyst event Disrupting the Health Care Landscape: New Roles for Familiar Players, held at NewYork-Presbyterian, October 25, 2018.

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