Analysis of the Cleveland Clinic Organisation

Introduction

There are many settings in the health care industry.  Most hospitals that were built was not planned for the healing of patients and the comfort of their family. Some would compare those earlier setting to that of a prison. This, however, is beginning to change in healthcare. Todays’ healthcare is moving more toward a patient centered and holistic genre. There is evidence that a good design improves patient outcomes and increase staff helpfulness and their morale. Most hospitals and/or clinics are seeing that a healing surrounding adds to the wellbeing of patient as well.

In this capstone project, I have selected to research the Cleveland Clinic. I selected this hospital because it is an outstanding medical center that is changing patient experiences.  I have a rare autoimmune condition and I have been suffering from this disease since I was 12. For years I have followed the research and studies that the Cleveland Clinic has done on Hidradenitis Suppurvita. Their research and outcome has been greatly received in the HS community.

Throughout this paper, there will be an analysis of the Cleveland Clinic and their facility physical settings, patient base and/or client base, the level of clinical activity and research, as well as their mission, vision and/or goals. It will also cover the community and global impact that this organization may have.  Section 2 will cover Cleveland Clinic financial management, their quality and ethics practices within the organization, and the various marketing aspects used by the organization.  There will be specific details on each area. In Section 3, the last part of the capstone paper, will cover the impact of economic and outside influence to the Cleveland Clinic, Healthcare reform, the national and world economy impact on the Cleveland Clinic.

Analysis of the Organization

The Cleveland Clinic is maintained and operated by the Cleveland Clinic Foundation. The main location is in Cleveland, Ohio and was started in February of 1921.  The four founding fathers were Franke E, Bunts, George. W. Crile, John Phillips and William E. Lower. The men want a hospital were medical experts can work together as a team.

As of January 2018, the CEO & President is Tomislav Mihaljevic, MD. The Clinic has ranked No. 2 in the 2018-19 U.S. News Best Hospitals Honor Rolls.  The Cleveland Clinic received a high score when it came to patient safety and exhibiting a dedication to reducing accidents and medical mistakes.  Mr. Mihaljevic has brought a notable range of experience with him. He know what it takes to accomplish effective clinical outcomes and inspire innovation, improve patient experience, cut healthcare costs, and improve access and affordability for patients.  His experiences makes him a great addition to the Cleveland Clinic.

The organizational structure of the Cleveland Clinic is much like any clinic.  The structure of the Cleveland Clinic is explained in forms of boards: Board of Directors, Board of Trustees, Board of Governors and the Executive Leadership. The Board of Directors are responsible for the primary governing of the whole body of the Cleveland Clinic. It has over twelve committees to ensure that it operates and maintains all its affairs. They help makes sure that they are organized and consistent with its mission. To date there are 23 members sitting on the Board of Directors and their services are voluntary.

The Board of Trustees roles is the advisory to the Directors; The Boards of Governors are the physician and/or surgeon who oversee the medical and surgical activities in the Clinic. The Board of Governors in the Clinic are also the one responsible for overseeing the integration of research and education with other services within the Cleveland Clinic. The Executive Leadership works alongside the Directors’ to manage the Clinic operations. The Executive Leadership include the CEO & President, Tom Mihaljevic, MD, the Chief Strategy Office, the Chief Patient Experience Office, to the Chief Human Resource Officers.

The Cleveland Clinic is a physician -led and enormous healthcare system.  It was created as a closed staff, not-for-profit, multidisciplinary group practice. The physician have an annually but salary contract.  There contracts are renewed annually through a process called the Annual Professional Review.

It has more than 1400 beds available on its main campus and close to 5000 beds systemwide, the clinic has a 44-building campus in Cleveland, and ten community hospitals located in Northeastern Ohio. There are approximately 18 outpatient family health centers including 10 ambulatory surgery centers and two specialized cancer centers located around Ohio. There is a hospital, several family health center and wellness center located in Florida.  The Cleveland Clinic has a specialized neurological and urological clinical in Nevada.

After World War II, the clinic begin to focus more on specialized medicine.  It has become a distinguished teaching health care system.  It has put together clinical and hospital care with research and education. Since building the Cleveland Clinic Coordinating Center for Clinical Research and the Lerner Research Institute, they can focus on clinical trials and studies the underlying causes of humans diseases and work on developing new treatment and cures.

In 2010 alone, The Cleveland Clinic had 22 active research projects going in just one of its many location. Their researches ranged from allergy/immunology to vascular medicine with several different areas of interest in each study. The advancement made in these areas have led to many benefits in terms of improved health, quality of ones’ life, the detection and diagnosis of the disease and treatment. Since the beginning of the Cleveland Clinic, research has been one of its core towers of strength.  The Clinic manages one of the biggest post-graduate medical education program and is a firm believer of continuing medical education for practicing physician’s.

As a multi-specialty hospital, it patient base are those of a with a medically complex history. It attracts patients from around the world. The patients that visit the Cleveland Clinic has condition that requires a team approach to provide a continuous, collaborative and more comprehensive care. The Clinic is design to offer various doctors ranging from heart, kidney, eyes, diabetic, children and woman health all in one location.  The Cleveland Clinic has several clients in its organizations being that it’s a multi-specialty clinic.  A few of their client are: Endocrinology, Dermatology, Cancer Center, Bariatric, and the Transplant Center. The Cleveland Clinic also has a Fertility Center as a client

While integrating it medical and education system at The Cleveland Clinic, medical researchers formally and scientifically test new types of treatment in clinical trials.  The Health System conducts extensive research and education activities. The Cleveland Clinic Foundation participated in a wide-ranging field of research activities including laboratory and in-vitro investigations, human subject research, therapeutic clinical trial studies, and other health outcomes research.

Cleveland Clinic websites states that their mission is “to provide better care of the sick, investigation into their problems, and further education of those who serve”.  In other words, they will do all they can do to get to the root of the illness of the individual while educating the provider in the process. For the clinic to accomplish their mission they must stride to excel in service and in their specialized medical care to the people that they service every day. They must ensure that they have the best qualified medical staff on board to reach their goals and uphold their standards.

Their vision a simple one to “be the front-runner in patient experience, clinical outcomes, research and education.” The clinic values are based on 6 principles, they believe that these six fundamental values forms the very foundation of the Clinic culture.  Quality, Innovation, Teamwork, Service, Integrity and Compassion.  With these values, the Founder have faith that the diversity of the many specialist working and thinking as one unit will foster an excellence in patient care, research and education which in hand follow their mission and help reach the vision they had for the Cleveland Clinic.

To help fulfil their mission, the Clinic attracts the top and best doctors to the best research scientists in the world.  Farther more, they are delivering education and research thru world-class specialized medical care all while sharing and developing new technology. They are committed to providing affordable medical care and giving every patient the best service possible.

The Cleveland Clinic has a strong role and history of serving the needs of the people in the communities. It provides uncompensated healthcare to many of in need, and engage in a wide range of medical research, teaching and training programs, and supporting communities health initiatives. The Clinic strive to provides quality healthcare and support efforts to improve health of our communities. They conduct full community health needs assessments to identify and plan for heaths need of the communities each of their hospitals serves.

The Cleveland Clinic is committed to bettering patients health no matter where they may live. They have promised to endorsed strategies and practices that advances the organization in ways that would benefit the economies and societies they serve. Area that they have progress in are human rights, environment, labor, social and anti-corruption as that relate to global goals. The global networks has been one of the many achievements of the Cleveland Clinic. Their strategy is focused around the five areas of treatment of international patients and hubs, telehealth efforts, counseling services, and education.

Section 2

Financial management is an important part of any establishment.  It consist of planning, to governing all aspect of financial actions.  Managing a company finance will have a vital impact on the company’s performance.  The Cleveland Clinic receives a lot of it funding from research projects and the many patients that visits the hospital.  Many of the Cleveland Clinic project are funded with competitive grants and contracts.  A competitive grant are given or awarded to area nonprofits, governmental facilities or schools. Cleveland Clinic has a startup incubator called CCF Innovations.  The CCF Innovations market Clinic Research and create startup companies. The Clinic received numerous awards such as the Wright Mega-Center for Innovation; receiving about $60 million.

In the year 2016, many hospitals were having an economic struggle, including the Cleveland Clinic.  They in fact witness a 71 % decline in operating income. After previously dropping, the Clinic saw a significant increase in it net operating income in 2017.  Their revenue increased about 5 %   giving them an operating margin of 4 %.  Cleveland Clinic attributed the growth to the increase access to urgent and express care visits and their virtual visits. The new CEO credited the systems revenue and operating gains to increased productivities.

Meanwhile, the Clinic research funding grew 4% with the hike in Their National Institutes of Health funding of 5% making it over 100 million. While the system ‘s revenue figure are changing so is the financial drivers. In the Cleveland Clinic, the CFO noticed an increased in the number of Medicare, Medicaid and self-pay patients but a reduction in commercially insured patients. The many years of having a flat reimbursement levels with Medicare have resulted in their program paying only 90% of hospital cost for the “senior, for patients that are worst off and the costlier patients. The payer system is changing their focus to aid lower-priced patients, including those using Medicaid.

Hospital are now using strategies to market their organization focus.  They are purchasing physician practices hoping to ensure continue referral volumes.  The Center for Medicare & Medicaid Service in 2017, announced a 1.6 billion cut to certain Medicare Part B drug payments. The CMS cut will include a decline in reimbursement for off-campus hospital outpatient department in the following years.  CMS hope that this more will provide a more level field for competition among hospitals and physician practices by endorsing a larger payment alignment.

The Government and Community Relations department in the Cleveland Clinic works with many law agencies at the local, state, and federal levels. They work with different agencies to focus on issues such as Ensuring Healthcare Access to Substance Abuse.  Their goals is to help form healthcare policy that are being created to make sure laws and regulations applied will serve the best interest of their patients. The Clinic focus their interest in issues related to access to healthcare, patient outcomes, quality of care, wellness, health information technology adoption, physician education and providers reimbursements.

Awards

The Cleveland Clinic is ranked the second-best hospital in the United States according to the U.S. News and World Report for the year 2018-2019 edition of “America Best Hospitals”. Over 20 years, the Clinic was ranked in the top group of best hospitals in the United States. Located on their main campus in Cleveland, the Heart and Vascular Institute received recognition as the best cardiology and heart surgery program in the States for 24 years. For two years, they received best urology program and is ranked nationally in fourteen specialties in the top five nationwide. They are among 20 hospitals to earn the U.S. News’ 2018-2019 Honor Roll.

The Clinic also ranked as a top pediatric hospital in the country.  The Children’s hospital received recognition in ten out of the ten medical specialties ranked.  For sixth times, the Ethisphere Institute acknowledged the Clinic as one of the World’s Most Ethical Companies.

The Ethisphere Institute defines and advance the standards of ethical business practices that power corporate character, marketplace responsibility, and business success. The awards that the Cleveland Clinic received recognized then for their promotion of ethical business standards and practices internally.  There are five categories in which they are ranked: ethics and compliance programs; company citizenship and responsibility; culture of ethics; governance; and leadership; innovation and status. Tomislav Mihaljevic, M.D, was named the sixteenth most influential physician executive in the nation by Modern Healthcare in 2018.

Accreditation

Accreditation benefits all stake holders in an organization.  Patients are the chief recipient in a healthcare system.  By getting an accreditation, you are saying that you are providing the highest quality of care and patient safety around. It tells the patients that they are being seen by a credential medical staff, their rights are respected and protected, and patient satisfaction is frequently assessed. It also shows that the staff are provided with continuous learning experience, a good working environment, management and the rights of the clinical processes.

When a health care organization get accreditation, it stimulates continuous improvement. Accreditation shows the organization commitment to quality of care; it raises community confidence in the services they are providing and provides opportunity for them to meet benchmark and compare themselves with the best.

The Cleveland Clinic is always ready for review when it comes to compliance.  They received accreditation based on the highest levels of quality care and patient safety standards set by The Joint Commission, the Centers for Medicare and Medicaid Services (CMS), the Ohio Department of Health and many other regulatory, licensing and accrediting agencies.

The CMS guarantee effective, informed healthcare coverage and endorse quality care for its beneficiaries.  The Joint Commission has the greatest impact of any single elements in the improvement of safety and security in healthcare. The goals of the Ohio Department of Health (ODH) is to protect and improved the health of the public by preventing disease and promoting good health, to assuring access to quality healthcare.

Being that The Cleveland Clinic is a multi-specialty hospital, they also have accreditation in specialty areas as well.  The Clinic hold over 17 different accreditations.  List of accreditations held by the Cleveland Clinic includes:

• Accreditation Council for Continuing Medical Education,
• Accreditation Council for Graduate Medication Education (ACGME),
• American Association of Blood Bank (AABB),
• American Association of Tissue Bank (AATB),
• American Board for Certification Orthotics and Prosthetics (ABC),
• The American College of Surgeons Bariatric Surgery Center Network,
• American Society of Bariatric Surgeons,
• The American Society for Histocompatibility and Immunogenetics (ASHI),
• COLA – Laboratory Accreditation,
• The College of American Pathologists (CAP),
• Commission on Dietetic Registration ,
• Commission on Dental Accreditation (CODA),
• The Joint Review Committee on Education in Radiologic Technology (JRCERT),
• The National Committee for Quality Assurance ,
• Ohio Department of Mental Health & Addiction Services‘,
• Commission on Accreditation of Rehabilitation Facilities (CARF),
• The Association for Clinical Pastoral Education, Inc. (ACPE)
• The United Network for Organ Sharing (UNOS) .

Regulations

Cleveland Clinic observes all laws and regulations that are required for hospitals and to keep their accreditations.  Hospitals that participate with Medicare must meet certain regulatory requirements.  Condition of participation for hospitals are that they must be licensed or approved in meeting the standards by those responsible for licensing the hospital in their states. They must have a governing body for the conduct of the hospital. There are also requirements imposed to protect patients’ health and safety. There are several laws designed to protect Americans’ personal health information.  Hospital must follow the guideline implement in the Privacy Act of 1974. This legislation allows individual to know what information is collected about them and allow them to obtain copies of that data. The Confidentiality of patient records and an Institutional Review Board are several other legislations that a hospital have in place to protect its patients and itself.

The Committee on Ethics at the Cleveland Clinic meets regularly to talk and evaluate policies and issues. The Clinic offers their’ Ethics Consultation Service to help with ethics advice to those involve in a dubious circumstance. They also provides educational programs regarding ethics issues for the professionals and the community.  Health specialists have an ethical responsibility to pursue actions that support delivery of effective health services and to discover and address injustice.

The code of conducts is part of the Cleveland Clinic’s general Compliance Programs. The Clinic comply with all laws designed to improve the workplace safety.  They are devoted to the highest standards of ethics and integrity.  The Patient Protection and Affordable Care Act (PPACA) established new guidelines in health care and states that everyone deserves access to basic health care.

The Cleveland Clinic brand is more than a logo or tagline.  It represents everything about who they are and what they want people to see.  Their brand represent the values, efforts and the mission of the hospital.  Brand is important to prospective patients.  Brands contributes to the reputation of the facility, it helps with healthcare plans acceptance.

The biggest marketing strategy goal for the Cleveland Clinic is awareness. They stride to do more than just write about treating the sick and doing research on the clinical conditions.  They want the world to know that they are focusing on preventative medicine as well.  The Clinic has multichannel marketing strategies. They blog content on a Health Hub that is available to the consumer audiences.  They always post on multiple social media channels, such as Facebook, Twitter, and LinkedIn.

The Cleveland Clinic market their content to different audiences and used the different sources to get their brand more awareness.  The Clinic has relationship with many partners to help with their brand awareness. Their biggest partners in their strategy is the community and their employees. When it comes to employees and the community, they are your representatives for your brand.  They will know the product and interact with each other daily. The employees respond to questions and concern and then post information online. They both will shares your vision and goals.  The community and employees are the ones sharing blogs post and social media content which is helping promote your brand and marketing strategy.

Section 3

National and world economy impact

Hospitals and other health systems are one of the largest employers in communities. Health care is an important part of a successful service economy. It makes important contribution to the economic progress.  When hospitals are doing well, the communities surrounding does too. Most hospitals are the major employers that impact the economy.  It covers money paid to health care providers and others affected in the field. It also includes services, equipment, and medicine. They employ nearly 6 million people making them the second largest source of private sector jobs in the U.S. The Cleveland Clinic came in as the second largest employer in Ohio. Their impact supports more than 200, 000 Ohio jobs. They are the biggest purchaser of goods and services and have made significant contributions to the state and local economies. There activities supports that of families, neighborhoods and the community as well.  Health care accounts for about one- sixth of the economy. Spending on health care totals over 2 billion.

Sustainability is defined as the potential benefits to the environment and society.  In today’s time, sustainability is embraced more aggressively within hospitals.  They see it as the linkage between greener operations, improved health care and the lowering of operating costs. Hospitals are placing greater importance on delivering greener products for use in patient care and the material used throughout their facilities.  The U.S. healthcare industry creates more than 5 million tons of waste yearly.  Sustainability measures have a direct financial return on hospital investments and integrating it into hospital/clinic operations came with some challenges. Many hospitals are placing more emphasis on linking their mission to a more sustainable health care operation.

Sustainability is growing among health care and can be seen by their procuring decisions and the constraints they are placing on the suppliers. Hospital facilities in the US have adopted the Environmentally Preferred Purchasing (EPP) program to ensure regards is being given to buying products with sustainable elements. The EPP program aids the U.S. federal government in using private sector improvement and then developing marketplace standards and ecolabels to identify and get the desirable products and services. (About the Environmentally Preferable Purchasing Program, 2017) While majority used the EPP program, there are many that uses a sustainability scorecard that requires suppliers to provide environmental reports about their products.  The sustainability scorecard calculates the energy and water use, recyclable materials, waste and gas emissions of the entire supplier chain.

Making a greener health care facility helps with the health and safety of the hospital employees and provides a great work environment as it is about delivering quality and cost-efficient patient care.  The health care industry have made significant strides in embracing and integrating environmental, social and financial sustainability.

The Cleveland Clinic Office for a Healthy Environment was started in 2007. It was created in response to the increased awareness of the environments impact and in respect of the link between environmental health and human health.  The program focuses on their buildings, their operations in creating a healthier-built environment, the ability of better buying of products and their involvement in educating and engages both the workforce and visitors.

The Cleveland Clinic has partner with Energy Star. They are using Energy Star rated appliances and equipment plus improving the energy productivity of their existing building. They are also members of the Practice Green health and the U.S. Green Building Council and is active in the Sustainable Cleveland 2019 initiative. The director of OHE, Jon Utech, leads the system green team, while they identifies best practices, updates progress, rolls out new programs and establishes priorities and goals in the Clinic.  In 2016, the Clinic creates a $7 million Green Revolving Fund. (Coutre, L ,2016) This fund uses money from energy-efficiency projects. They replenished the fund with the saving investments they received from the reduced energy consumption and rebates. Health care is constantly looking for ways to improve the health of the communities in which they serve.

Reform in health care is an involved process and consist of many different aspects. Many feels that the system needs a complete overhaul, while others think just some areas need minor improvement.  The main goals of the health care reform is to provide healthcare insurance for all Americans that are uninsured and to decrease the cost of services and coverage.  Reform in Health care is needed in the United States because the cost of health care is too high. The cost of preventative care was excessive and sent most low-income people to the emergency room which in turn raised the cost of health care. Secondly, health care reform is said to improve the quality of care. Also, health care reform will cover over 25% of the Americans who have little or no health insurance.  Each year, thousands die because of the lack of insurance to go to see a doctor. Health Care reform is also needed to stop the cost of health care fraud.

The Affordable Care Act has taken steps to address the issues in health care. The ACA makes sure that individual get fair treatment by providers. It makes health insurance more affordable and it offers consumer protections. Protection that are protected such as stopping insurance companies from denying coverage based on health status, dropping you when you are sick and giving you the right to an appeal of insurance decisions. Improved quality of care and changes in payments are a result of the health care reform.

In 2012, the then Cleveland Clinic President and CEO, Delos M. Cosgrove, MD calls the Supreme Court decision “a monumental moment” in history. (News Team, 2012). Dr. Cosgrove, M.D. states that the decision means that the hospital is moving ahead on the journey of reforming healthcare in the United States and that they are ensuring access for people who haven’t had access before. He also explain that the Clinic will continue to address quality and develop a more efficient healthcare delivery system. (News Team, 2012) Its seems that health care reform is working.  More young people became insured.  The age for children increased to 26 and they can be covered by their parents’ insurance.  The profits for insurance companies increased which in theory lower the premiums.  More small business are offering health care benefits than previous years.

The Cleveland Clinic, a multi-specialty clinical organization delivers medical and hospital treatment in an expert setting.  The Cleveland Clinic model of care is a physician-led multispecialty group practice.  Their staff is salaried and are a one-year contract that is renewable after a year performance review. The Clinic integrates its research and academic institutes to provide top knots services to the communities it serves. The Cleveland Clinic has several hospitals across the US, Canada and the Abu Dhabi.  It also have several family centers, surgery centers and other various specialties department.

Since the beginning, the Cleveland Clinic has grown by leaps and bounds. They have done this by building a large network and expanding and extending its presence. The Clinic has a system where excellent doctors and caregivers can perform at their best, advance their profession and provide first-rate care for all its patients. The Cleveland Clinic continues to follow its mission and work on making their vision come to life.  They are known as a national leader and have a superb model of healthcare.

The physicians treat the most complex medical cases in the U.S. and around the world.  They excels in providing specialized medical care supported by research and education. It is putting patients first as it focus on measurable quality. They have established and met benchmarks to measure and improve the quality of care they are providing. They have encouraged and empowered discovery in research, education and patient care.  The executive and senior leadership are committed to enhancing the patient experience.

The history of the clinic is very strong. They have already begun adopting digital technology to deliver smarter, affordable and accessible care. Their impact on patient care and the clinical experience extends beyond the city, state and the world. The Cleveland Clinic will be expanding their affiliate network and will be looking into additional clinical areas.  In the State of the Clinic address in February 2018, the president and CEO of Cleveland Clinic, Tom Mihaljevic stated that they are creating new initiatives to improve patient safety and reduce provider burnout. (Cleveland Clinic News Services, 2018) The growth of the Cleveland Clinic is unstoppable.  Overall, they have 32 clinical hospital affiliations and alliances in seven states and the D.C. area.  They have recently joined with Medstar Southern Maryland Hospital Center (MSMHC) in 2017.  This addition gives the Clinic a total of 21 heart, 3 oncology, 5 neurology, 2 transplant and one bariatric clinical area. As the Clinic extend it network, they will be focusing more on quality of care they provide for a better clinical outcome.  I see the Cleveland Clinic extending their brands well across the world and attracting more national employer and employee.  I see the Cleveland Clinic joining many other hospitals affiliates as they work together to accelerate improvements in heart care, research and to support better patients outcomes.

In this paper, I have covered a breakdown of the Cleveland Clinic and their facility, their clinical doings and research, as well as the companies mission, vision and/or goals. I have touched on the community and global impact of the Clinic.  This report also covered Cleveland Clinic financial management, their quality and ethics practices, and their marketing.  Lastly, the report addresses the impact of the economic influence of the Cleveland Clinic, what the Clinic is focus on with Healthcare reform and the impact of the economy nationally and global.

References

Best Hospital U.S. News Ranking, 2018-2019, Cleveland Clinic. Retrieved From https://health.usnews.com/best-hospitals/area/oh/cleveland-clinic-6410670

CHAPTER IV – CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED).

SUBCHAPTER G – STANDARDS AND CERTIFICATION. (2011) Code of Federal Regulations. Retrieved From https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/xml/CFR-2011-title42-vol5-part482.xml

Cleveland Clinic. Retrieved From https://my.clevelandclinic.org/about/overview

Cleveland Clinic. 2010-2011 Excellence in Medical Education and Research  Retrieved From   https://my.clevelandclinic.org/ccf/media/files/Florida/Development/excellence-in-medical-education-2012.pdf

Cleveland Clinic Office for a Healthy Environment 2015. Retrieved from, http://portals.clevelandclinic.org/ungc2015/Reporting/Organizational-Profile#23548762-who-are-our-patients–

Cleveland Clinic Foundation 2016 Interim Inaudited Solidated Financial Statement and Other Information. Retrieved from https://emma.msrb.org/EP951599-EP738174-.pdf

Cleveland Clinic News Services, 2018 Cleveland Clinic President and CEO Tom Mihaljevic, M.D., Delivers State of the Clinic Address Retrieved From https://newsroom.clevelandclinic.org/2018/02/28/cleveland-clinic-president-and-ceo-tom-mihaljevic-m-d-delivers-state-of-the-clinic-address/

Coutre, L (2016) Cleveland Clinic establishes $7.5 million Green Revolving Fund. Retrieved From https://www.modernhealthcare.com/article/20160510/NEWS/160519998

News Team, (2012) Cleveland Clinic Responds to Affordable Care Act Ruling (Video). Retrieved From https://health.clevelandclinic.org/healthcare-reform-cleveland-clinic-responds/

Pearl, M.D., R (2017) Why Major Hospitals Are Losing Money by The Millions Retrieved from https://www.forbes.com/sites/robertpearl/2017/11/07/hospitals-losing-millions/#30260a5d7b50

Rush, B (2014) Healthcare Marketing: Behind the Scenes of The Cleveland Clinic’s Content Marketing Strategy. Retrieved from https://www.kunocreative.com/blog/cleveland-clinics-content-marketing-strategy

Sorrell, J., (November 9, 2012) “Ethics: The Patient Protection and Affordable Care Act: Ethical Perspectives in 21st Century Health Care” OJIN: The Online Journal of Issues in Nursing Vol. 18 No. 1. Retrieved From http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/Patient-Protection-and-Affordable-Care-Act-Ethical-Perspectives.html#Grace

Sutter, K,. (Year). The Growing Important of More Sustainable Products in The Global  Health care Industry. Retrieved From https://www.jnj.com/_document?id=00000159-6a81-dba3-afdb-7aeba25f0000

The United Stated Environmental Protection Agency (2017) Sustainable Marketplace: Greener Products and Services, About the Environmentally Preferable Purchasing Program. Retrieved From  https://www.epa.gov/greenerproducts/about-environmentally-preferable-purchasing-program