Inheriting a medical mess

Things were not good when Grossman arrived at New York University Medical Center to run the radiology department in 2001. He was days into the role when a pipe burst in his office, leaving a pile of plaster and unsightly debris. It took eight weeks to get someone from the organization to fix it, because no one would take ownership: Was the medical school responsible for the wall, or the hospital? 

To Grossman, who had come from Penn, the absurd situation symbolized the inefficiency and dysfunction that ailed NYUMC and academic medicine more broadly. When he became dean and CEO in 2007, Grossman vowed to run the school and hospital as a single integrated entity. He also boldly committed to make the institution “world-class”—“an academic medical center competing successfully with the Hopkins, the Harvards and Penns,” he wrote in his investiture speech.

Langone, a self-made business titan who, before co-founding Home Depot, had taken Electronic Data Systems public with Ross Perot, shared Grossman’s lofty goals. He had joined the board in 1999 when his friend, Martin Lipton, an M&A attorney and NYU trustee, told Langone he needed help with a mess at the medical center.  (A graduate of NYU’s business school, Langone says he didn’t even realize NYU had a medical center.)

That mess: a 1998 merger with Mount Sinai that had gone so badly that the hospitals broke up a few years later. By 2003, the combined entity had racked up three straight years of losses, $670 million in debt, and a junk-bond rating. The institution was independent again, but not profitable, when Grossman got promoted in 2007.

Langone and Grossman had bonded several years earlier when Grossman, wanting to replace his department’s radiology equipment, had put out a request for proposals. Showing some raw business talent, he negotiated an unthinkably good deal with Siemens: The medtech company agreed to give NYU the technology, plus $100 million for NYU to serve as a showroom. Those terms impressed Langone, who happened to be on the board of General Electric, a losing bidder. That Langone didn’t let that conflict—or his friendship with GE’s then-CEO Jack Welch—interfere with the Siemens deal, meanwhile, impressed Grossman.

Over the years, the two have become incredibly close, trading regular phone calls and referring to each other as “brothers from different mothers.” Grossman attributes their kinship to their hardscrabble childhoods and the resilience it fostered. He was a scholarship kid who described his mom to me as “an illegal immigrant.” Langone’s parents, also immigrants, worked as a plumber and a cafeteria worker, and didn’t get schooling beyond junior high.

Langone, 11 years Grossman’s senior, plays the gregarious and protective older sibling in the relationship. When I met him at his Park Avenue office, he heaped praise on Grossman—“He’s brilliant…values beyond reproach…this guy could take my job doing deals!”  (When it comes to himself, Langone’s prone to absurd self-effacement: “I’m not the brightest bulb,” he tends to say, emphasizing his science education ended in 8th grade.)  The big-brother vibe plays out practically too: Grossman, who described Langone as “the best guy in the world,” says he’s a keenly intelligent sounding board, and some extra muscle. “We deal with politicians, and he’s connected, and that’s very important as well.”

The board sees the duo’s dynamic as a key to NYU Langone’s success. Murphy describes Grossman as the transformation’s visionary, and Langone as its enabling force. Fink, who points out his firm owns 5%-10% of virtually every major company in the world, says, “I see some really good leadership and some really crappy leadership, but it was very clear, very early on that the chemistry between Bob and Ken was something very unique.” He adds, “Bob grew into the CEO role—a lot of it was the trust he had with Ken, and maybe a little bit with me.”  

Grossman’s leadership was a shock to the broader system, however. He fired most of the executive team before his first day. Not long after, he ripped out a relatively new $35 million electronic health-record system, telling the board he needed to install the more expensive Epic system instead. 

Rather than acquiring hospitals—the go-to strategy for health systems at the time—Grossman committed to building a network of outpatient facilities, correctly anticipating that technology would allow an increasing share of procedures to be performed outside of hospitals. (That strategy has paid off: Ambulatory facilities don’t require 24/7 staffing and are more profitable.)

Relaying the events to me 18 years later, Grossman still seemed tickled by his own audacity, and the fact that he has shown up naysayers, like a McKinsey consultant who told him he was doing too many things too fast.

Satisfying too, was his experience watching a class at Harvard Business School discuss NYU Langone, the case study. The students struck Grossman as timid: They’d all viewed his early management purge—“Black Wednesday,” as it became known—as cataclysmic. “I didn’t think it was any big deal,” he told me. “I just didn’t think the institution was functioning.” 

Dr. Andrew Brotman, NYU Langone’s outgoing chief clinical officer, recalls that Grossman fired people he was friendly with that day, with no apparent anguish. That sort of compartmentalization is “characteristic of Bob,” he told me. “He does what’s best for the organization.” 

Fiona Druckenmiller, a former portfolio manager who joined NYU Langone’s board in 2006—and who will succeed Langone as chair on Sept. 1— describes Bob “as one of the most decisive people I’ve ever met.”

An all-seeing data ‘dashboard’

The key to decision-making at NYU Langone is the “dashboard,” a data-rich tool that tracks more than 800 metrics across the system in real time. Grossman created the platform, which he refers to as the organization’s “sole source of truth,” with the help of a small, select team early in his tenure; he felt the input of other managers would muddy his vision. 

The dashboard captures everything from teacher evaluations and high-impact publications to ICU bed space and operating-room turnover time. It’s how Grossman obsessively manages the place, and how the contribution of every department, physician, nursing unit, and administrator is measured. 

Big data is hardly novel in the corporate world, but the analytics that has already revolutionized most industries has been slower to transform health care, due to clumsy IT systems, fragmented providers, and heightened privacy concerns. Perhaps what sets NYU Langone’s dashboard apart is its thoroughness and its centrality to the organization. 

I was eager to see the dashboard data through Grossman’s eyes, and he agreed to give me a demonstration one morning. He clicked through his go-to pages—one flagging trending data across the system, another showing emergency department stats. (Average “door to doc time” that morning: 13 minutes; average time in ER: 4.5 hours, which Grossman described as “damn good.”) We looked up his own dashboard usage (269 log-ins in the past year; enough to put him in the top 2.5% of the system’s users, but well short of his Chief of Hospital Operations, Dr. Fritz François, whose count topped 4,000.)

The granularity of data has been key to identifying issues and fixing them. Even before the dashboard came online, for example, Grossman noticed a quirk with the NYU Langone’s “case mix index,” a measure that reflects the complexity of patient cases and care provided. Grossman realized that physicians weren’t fully documenting cases, and as a result, weren’t being fully reimbursed for care. A major documentation effort followed, an exercise which helped turn around the organization’s finances. 

If Grossman has a north star metric, it’s “length of stay.” Hospital operations are more profitable, in essence, when in-patient stays are short, and so length-of-stay has become an NYU Langone benchmark of focus. To some, that may sound sinister, like an incentive for kicking patients out before they’re ready to go home. But there’s considerable evidence that unnecessary time in the hospital can do patients more harm than good, increasing their risk of infection or other complications, which are also costly for the system. 

NYU Langone now has one of the nation’s lowest average lengths of stay—something Grossman could show me thanks to third-party data that populates the dashboard and allows comparing NYU Langone to 115 other large health systems. He navigated over to a screen ranking hospitals by observed-to-expected mortality. The dashboard showed NYU Langone with the lowest mortality index, which Grossman pointed out before somewhat gleefully namechecking his lagging rivals. “New York-Presbyterian, probably twice the mortality,” he noted, scanning the list. “University of Pennsylvania…Duke… Here’s North Shore—four times the mortality!” he exclaimed, breaking into a hearty chuckle. (It should be noted that because NYU Langone’s rate was very low—32 patients dying when 100 would have been expected to die in similar circumstances—those competitors had death rates that were roughly in line with or better than industry standards.)

 “Bob is very competitive,” Druckenmiller later told me, “He does keep track of how everyone else is doing.”

The dashboard is key to keeping operations on track, but Grossman says it’s more important impact has been on culture. To make his point, he showed me the page of a faculty member: Dr. Robert Montgomery, an award-winning transplant surgeon with a prodigious handlebar moustache. He pointed out the range of available stats (on-time OR starts, patient infection rates, grant funding) and double-clicked on a few to show how Montgomery ranked among colleagues. I asked if this feature led some doctors to obsessively check their own performance. “Well, that’s the behavior,” Grossman said matter-of-factly. “That’s how you become number one.” 

Are there any limitations to the metrics or cases where they aren’t fair? Plenty of faculty members have challenged assessments that they’re underproductive, Grossman says, but when that happens, he can simply point them to the dashboard: Why do they have zero grants or zero high-impact publications when others in the same department have several? The measures are objective, he says, and the system fully transparent.

Even as I marveled at the data available, I wondered if the dashboard-driven culture—part Moneyball, part panopticon— might feel oppressive to some. “It’s not for everyone,” Brotman later told me. “You’re on the hook 24/7, 365, and you’ve got this vulnerability and this expectation of accountability. If you don’t have the right disposition, it’s hard to deal with.”  

I felt awkward simply being in the room for moments of the “Snapshot Review,” a meeting where the chairs of clinical departments filed onstage for dashboard-informed questioning from administrators. The review sessions, in an airy conference room overlooking the East River, varied considerably in tone and substance. Some involved praise and practical problem-solving; others, discussions of “low-performing faculty members”; and another—featuring a relatively new leader who clearly hadn’t found his footing—the feel of a man pleading for mercy.  

Over time, NYU Langone leaders have gotten better at identifying the people who buy into the culture and thrive, and those who don’t. (The health system claims an approximate 10% annual employee turnover rate.) Who does thrive? People who like data, who accept that medicine is a science and not an art (NYU standardizes processes, right down to the surgical tools used). 

A theme that came up in my interviews—somewhat surprisingly, at a high-performing health system—was how little people sleep. “Bob doesn’t turn off,” Druckenmiller said of Grossman. She explained that a lot of the hospital’s most important business gets done over phone calls at 4:30 in the morning, because that’s an hour when Langone, Grossman, and she (and others) are all awake and not commuting yet. She said that Grossman’s successor, Dr. Alec Kimmelman, is that way too. (When Druckenmiller asked Kimmelman’s wife if she was ready for him to take on the role, she answered she didn’t expect anything would change—he was gone before she woke up and home after she went to bed.) When I asked Langone how he managed it all, he told me, “I don’t sleep. The other guy’s sleeping while I’m doing other stuff.”  

The culture of self-care has not yet come for NYU Langone leadership, but work-life balance is on its radar. At a Snapshot review meeting I attended, there was discussion of the outgoing infectious disease chief, and how his “Iron Man Model” was not as in-fashion with the younger generation of doctors. Kimmelman, who comes across as thoughtful and laid-back, assured me NYU Langone’s culture welcomes non-workaholics. What matters, he says, is that “even if their attitudes towards work-life balance are different than mine, they’re still devoted to excellence and quality and taking great care of patients.”

Courtesy of NYU Langone Health

 At the time of my visit, I had just finished watching The Pitt, the HBO medical drama focused on one chaotic, 15-hour shift in a Pittsburgh emergency room. Throughout the series, a suit-wearing, metrics-obsessed administrator drops by to scold the staff on the measures in which they’re falling short— wait times, patient satisfaction scores, documentation—ratcheting up the pressure on overstretched doctors and nurses trying to save lives.  One naturally sympathizes with the staff, but it can be easy to overlook that the administrator’s goals—however warped by the economics of the health system—are actually in the interest of patient care, or at least of keeping the hospital’s doors open. (Grossman hadn’t watched the show. “I don’t think it’s my cup of tea,” he told me.)

It can be easy to vilify micromanagement, but Dr. Oren Cahlon, a radiation oncologist who will take Brotman’s job in September—says it has been effective at NYU Langone. 

Recently Cahlon had been digging into patient access issues—the long wait times new patients face to make appointments at NYU. He’d been plumbing physicians’ schedules, drawing up new policies—How often did patients really need follow-up appointments? Could some of those existing patients see a nurse practitioner or physician assistant instead? —and even changing compensation models to incentivize providers to see new patients. Brotman approvingly compared Cahlon’s work to “guerilla warfare,” noting that he’d managed to increase new-patient appointments by 10% to 40%. It hadn’t immediately gone over well, but Brotman and Cahlon had engaged staff and patients about the reasons for the changes. Contrary to the concerns that adding more patients would cause burnout and tank satisfaction scores, Brotman says they’ve seen the opposite. 

Taking the business model outside Manhattan

A 30-minute ferry ride from NYU’s gleaming Manhattan campus delivers you to the health system’s Brooklyn hospital, on the industrial fringes of Sunset Park. The facility, wrapped in scaffolding due to ongoing renovation, is shabbier than the midtown mothership. It serves a diverse population, many of whom are not native English speakers, and 82% of whom depend on government insurance.

But the care and increasingly the range of services match those back at headquarters. Since NYU Langone completed its merger with Lutheran, a struggling community hospital, in 2016, its patient safety and health outcome measures have vastly improved. (Observed-to-expected mortality has fallen 60% since 2017; complications have come down 58%.) And it’s profitable this year, because it’s seeing more patients, and seeing them more efficiently. 

Getting there involved many years of taking the same fine-tooth-comb data-driven approach to hospital operations. When NYU took over, most of the doctors there were contractors, and the under-resourced facility was working with outdated infrastructure and technology: Cardiologists, for example, would view electrocardiograms on VHS tapes. 

Courtesy of NYU Langone Health

There’s often suspicion and fear when a large health system acquires a smaller community hospital, and it’s well-founded; big systems often strip their acquisitions of services and send patients to their larger facilities for sophisticated care. NYU Langone met with similar skepticism, but the result has been the opposite: it invested in the Brooklyn hospital, hired a full-time staff, and added a range of higher-end services—cardiac catheterization labs, neurosurgery, cancer care—bringing care into the community. 

The day I visited, I found Dr. Bret Rudy, chief of hospital operations, in his office, studying dashboard data on a large monitor. It was 9:45 a.m., and so far, 41 patients had arrived in the emergency department; seven were waiting for beds, including one whose digital profile he clicked on for my benefit, who was being admitted for a possible case of tuberculosis. Rudy navigated to operating stats—where 92% of the day’s first procedures that month had started on time. “That should be higher,” he said, explaining that turnaround time between procedures should be 30 minutes or less. The dashboard had allowed him and a pair of surgeons he’d deputized to optimize workflow, investigating late starts and rooting out inefficiencies. Since 2017, they’ve increased the number of surgeries by more than 20% (a total of 2,000 more surgeries per year), through disciplined scheduling and 6 a.m. start-times. 

Nine years in, NYU Langone Hospital-Brooklyn is practically a well-oiled machine. The front lines of NYU’s transformation effort have shifted to Patchogue, a town on 12,000 on Long Island, where it recently completed a merger with a community hospital, now known as NYU Langone Hospital-Suffolk. Suffolk County is famed for the glitzy Hamptons, but closer to Patchogue it’s home to working-class towns troubled by the opioid epidemic and MS-13 gang activity. 

The Suffolk County hospital was in rough shape when NYU Langone entered the picture a few years ago; after years of underinvestment, its reputation had suffered, and patients that ended up there tended to be either very sick or accident victims brought in from the Long Island Expressway. Other health systems had considered purchasing the hospital but always walked away; Dr. Marc Adler, chief of hospital operations, recalls that when he first introduced himself, a staff member said, “You’ll be gone in three months.”

Adler is now several years into the job, implementing the NYU Langone playbook. The patient population is largely covered by Medicare and Medicaid, and it suffers from greater levels of substance abuse and mental health issues than NYU Langone-Brooklyn’s does. Among NYU’s first investments were a larger security staff and a new behavioral health facility; surgical robots and new operating rooms have been added too. They’ve hired a new full-time staff, some poached from NYU’s hospital in neighboring Nassau County. 

There had been plenty of room for efficiency improvements at the hospital.  “If everyone’s coming in at 9 a.m., you’re never going to start your cases at 7 a.m.,” says Adler. Only 30% of the day’s first surgeries started on time in 2021. The doctors, who were on contract and would stop by only a few days per week, erred on the side of longer stays—keeping patients in the hospital over the weekend or for another day if they hadn’t seen them.

Adler of course, showed me his dashboard. The quality of care and patient outcomes are much improved over the past few years, and over 90% of the day’s first cases now start on time. NYU Langone Hospital-Suffolk has a “C” safety grade by the standards of Leapfrog Group, a hospital ranking group—all other NYU hospitals have an “A”—but Adler explains it’s due to Leapfrog’s methodology, which relies on data from up to three years prior. NYU Langone executives say the level of care is now equivalent to the system’s other hospitals.

Federal cuts, personal triumphs

Like other nonprofit health systems, NYU Langone is facing cuts to Medicaid and NIH funding. Last year, the NYU Grossman School of Medicine ranked 11^th in terms of NIH awards, with $490 million in funding according to the Blue Ridge Institute for Medical Research, which tracks the field. According to BRIMR’s analysis, NYU’s medical school has so far had a handful of grants worth $12 million terminated; 56 schools had greater losses in funding.

“Obviously we think a lot about that,” Kimmelman, Grossman’s successor, tells me. Like a lot of institutions, NYU Langone is looking at ways to diversify research funding from other sources, and some affected researchers have had to pivot. 

At the same time, Kimmelman says his team is trying to not let the uncertainty distract them from their mission or the various expansion projects already in motion. He takes inspiration from Grossman, who in the depths of COVID, a financially perilous period, didn’t hesitate to invest in important but extremely expensive technology. The decision came down to impact on patient care.  “I think our fundamentals are incredibly solid,” Kimmelman says. “If we can’t thrive or survive in whatever happens to NIH, I don’t think there’s going to be any health care system that can.” 

It’s not the first time a dire situation has largely been out of NYU Langone’s control. Many vividly remember the night in 2012 when Hurricane Sandy plunged lower Manhattan and NYU Langone (its generators failed) into darkness, flooding the Manhattan campus and shuttering the hospital and medical school for several weeks. “I thought it was all over,” says Brotman. 

Langone happened to be a patient that night, recovering from pneumonia. He was evacuated from the 17^th floor at 3 a.m., along with 23 infants staying in the neo-natal intensive care unit. Langone vividly remembers following the procession—the babies still attached to tubes, each one cradled by a nurse lying on a sled, while others carefully carried the sled and medical equipment down the pitch-dark stairway—and the sound of nurses, in perfect unison, saying “Step, step, step,” until they made it to the ground floor.

John Minchillo—AP Photo

It’s still one of his proudest moments. And as instrumental as he has been to NYU Langone’s recovery and its broader accomplishments, the day I visited him Langone kept steering me back to the system’s smaller, anecdotal triumphs—like the too-scared-to-sleep heart transplant patient who was comforted in the middle of the night by a kind building services worker.

While Grossman’s laser focus on industry-leading care is filtered through an obsessive, data-driven wonkiness, Langone relishes the human stories, the living, breathing proof their work has made a difference. On his desk, behind boxes of Dots Christmas candy, framed photos, and a sign that reads “The Buck Stops Here,” were cards that he’d occasionally pick up mid-conversation and read to me—from grateful patients, or family members, or former employees, thanking him for their experience at NYU Langone. “I’ve got a bunch of them,” he told me, as if the testimonies answered all remaining questions. He always writes a note back.