The CFA Perspective

The National Low Volume Cardiac Surgery Conundrum

Posted by John Meyer, FACHE

Apr 14, 2017 6:00:00 AM

The national decline in cardiac surgical volumes is well documented:  between 2000 and 2010, annual isolated CABG volume in the U.S. declined by 95,000 cases (from 314,000 to 219,000), a drop of 30%.  As a microcosm of national trends, California data reporting isolated CABG surgeries between 2005 and 2015 documents a similar trend among the state’s 125 hospitals currently licensed to provide this service.[1]  As total CABG volume has fallen, average per-hospital CABG volumes have fallen concomitantly, putting increased pressure on low volume programs to meet both internal financial performance goals and clinical and outcome expectations.  Thus, low cardiac surgical volumes continue to be an issue for both hospital systems with multiple cardiac surgical providers, as well as single hospital providers who may face volume-related issues.

CABG-Only Surgery Volume in California.png

The Decline in California CABG Volumes Parallel U.S. Declines

California reported a decline in total CABG surgery from 21,295 discharges in 2005 to 15,278 in 2015 (see table), a decline of 6,017 or 28.3%.  In 2005, 119 hospitals reported performing CABG surgery, with an average of 178 discharges.  This declined to an average of 97 CABG discharges reported for 125 hospitals (6 more hospitals than in 2005!) in 2015.  There were 65 hospitals in California that reported fewer than 100 CABG surgeries in 2015 ‒ frankly, more than in some entire states or regions of the country.  The average CABG volume for California hospitals reporting fewer than 100 surgeries per year was 58.  Clearly, the issue of low volume is widespread and increasingly relevant.

What is a Low Volume Hospital to Do?

There is no universally-accepted, recommended program minimum volume standard for CABG, valve or total cardiac surgery.  However, beyond specific state-mandated minimums for licensure/certification (if present) and/or professional societal recommendations, common sense would indicate that a hospital with a total annual volume under 100 – and most certainly under 50 – is by any definition a “low volume” program.

The question becomes, can a low volume program be both relevant and insure its survival by producing excellent results?  CFA believes that it can, and so do rating agencies like Truven Health Analytics Top 50 Cardiovascular Hospitals in 2017 (see Can Low Volume Cardiac Surgery Programs be Excellent? ).  But it is extremely challenging.  In this era of value creation and increasing data transparency, a low volume program without excellent performance can be detrimental to any hospital’s financial performance, overall reputation and market position.

We have found that many low volume programs actually provide more cost effective, clinically superior outcomes than some higher volume programs.  This might seem to fly in the face of other “conventional” data showing low volume programs generally have worse, not better, outcomes.  In our experience, great program-dedicated surgeons, assiduous case selection, strong teams and adherence to best practices are more important factors than gross statistics and large volumes alone relative to clinical performance and operational outcomes

CFA has written extensively on low-volume surgery programs, most specifically in its white paper, Low Volume Cardiac Surgery:  Grow, Consolidate or Divest?  The Need for Next Generation Assessment.  We would call your attention to this document for a detailed explanation of approaches to assessing a low volume program with an eye towards taking remedial action.  It would be overly simplistic to insist that every low volume program is either unnecessary or redundant in its market area, needs to be consolidated with another provider, or cannot be upgraded or salvaged with proper assistance.  There are options that can be explored and strategies that can be implemented before any cardiac surgery program is deemed “unsalvageable.”  You can access the CFA Low Volume Cardiac Surgery white paper.

It is important to stress that these potential program “fixes” can be attempted only after a “next generation assessment,” which correctly diagnoses the critical issues that differentiate a salvageable program from one that is fatally flawed.  Having consulted with hundreds of cardiac programs over the course of my career, I can tell you from experience that if you believe the source of all problems centers on the surgeon(s), you might be wrong; there are a myriad of subtle and not-so-subtle reasons underlying overall program performance, not all of which can be laid at the feet of the surgeon(s).


All low volume cardiac surgical programs need to be aware that they are increasingly vulnerable from both outside market forces (e.g., competition, data transparency, payer scrutiny, patient expectations and experience, outside rating agencies, payment reform including bundled payment models) and internal performance expectations.  An appropriate assessment of any program by an outside consultant or content expert should reveal the core issues that are preventing optimal performance.  Typically, it is a myriad of issues and not just a single one that is at the root of the problem.

In conclusion, and in the face of continuing declining cardiac surgical volumes, low volume programs can be top performers in quality and cost measures – but they are the exception, rather than the rule.  To be the exception takes extraordinary vision, leadership, collaboration and team-building, which many hospitals are challenged to provide.  The majority of hospitals with low volume programs will need to continue to strive for performance excellence, as a means of self-preservation in the short term, and ultimately long-term success for the institution as a whole.  Should attempts to revitalize a low volume program fail, this may inevitably lead to consolidation or divestiture simply due to the changing health care delivery and payer markets and the need to successfully focus on attaining value-based status.

If you are interested in learning more about strategies to deal with low volume cardiac surgery programs and/or programmatic consolidation for cardiovascular or other services, please contact CFA at (949) 443-4005 or by e-mail at  

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[1] Unfortunately, the California CCORP data does not separately track cardiac valve surgery, but “other” non-CABG cardiac procedures count for 57% of the total, which predominantly includes valves.

Innovative Pathways of Care Can Reduce Resource Utilization, Enhance Quality

Posted by John Meyer, FACHE

Mar 31, 2017 8:27:57 AM

Image for Innovative Pathways blog 3-29-17.jpgIn the continuing effort to foster innovation and cost savings in cardiovascular programs, CFA was reminded of two interrelated clinical pathway issues by recently published research.  In looking for ways to improve outcomes and decrease the cost of interventional cardiology procedures, the concept of transradial versus transfemoral arterial access has received considerable attention in recent years.  Additionally, the transition of select PCI procedures[1] from inpatient status to same-day discharge has also grown considerably.  Combined, utilizing the transradial approach for select PCI procedures, allowing patients to achieve same-day discharge, is growing steadily, although at a slow rate.

The first study was published in JACC:  Cardiovascular Innovations:

JACC Study Findings

Costs Associated with Access Site and Same-Day discharge Among Medicare Beneficiaries Undergoing Percutaneous Coronary Intervention:  An Evaluation of the Current Percutaneous Coronary Intervention Care Pathways in the United States.  JACC:  Cardiovascular Interventions, Vol. 10, No. 4, 2017.


Among Medicare beneficiaries, transradial intervention (TRI) with same-day discharge (SDD) was independently associated with fewer complications and lower in-hospital costs.


These findings have important implications for changing the current PCI care pathways to improve outcomes and reduce costs.  Shifting current practice from transfemoral intervention non-same day discharge to TRI SSD by 30% could potentially save a hospital performing 1,000 PCIs each year $1 million and the U.S. $300 million annually.

The second, supporting piece of research comes from the updated ACC National Cardiovascular Data Registry (NCDR) CathPCI data released in February:

Updated ACC Registry Data Release Findings

ACC National Cardiovascular Data Registry (NCDR), CY 2014 data release, ACC, February 14, 2017.


25.2% of PCI procedures in 2014 were performed by the radial approach, up from 10.9% in 2011.


This is an important finding, as it supports the continuing growth of TRI in the U.S.  Unfortunately, they did not report the growth of SDD.

While national data on SDD is difficult to obtain, it is believed that the typical average SDD rate is about 35% (and varies by diagnosis, procedure and presence/absence of complications and comorbidities).  There is considerable anecdotal information from progressive hospitals suggesting that, depending upon the inclusion/exclusion criteria used, and ultimately the mix of patients, rates approaching the 50% to 75% range can be reached.  While TRI and SDD are somewhat dependent variables in the above referenced studies, they are not completely dependent.  SDD can occur with patients who experience a transfemoral approach procedure.  

Further supporting documentation from a joint consensus document on transradial PCI, published in January 2013 by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the Acute Cardiovascular Care Association (ACCA) and the Working Group (WG) on Thrombosis of the European Society of Cardiology (ESC), the European Society of Cardiology in a press release stated:

“The radial approach for percutaneous coronary interventions (PCI) was developed 20 years ago and is used for more than 50% of procedures in France, Scandinavian countries, the UK, Spain and Italy. Despite the advantages of radial access some countries in Europe such as Germany use radial access for fewer than 10% of PCI….

“Evidence has accumulated in the literature showing the benefits of radial over femoral access for PCI including reduced bleeding and improved survival. In addition, the development of smaller and thinner devices has made the radial approach increasingly practical.”[2}



Both TRI and SDD represent significant departures from traditional pathways of care utilized by most interventional cardiologists in the U.S.[3]  Progressive hospitals and their medical staffs have adopted these two major changes as continuing research has documented better outcomes, lower costs and enhanced patient experience.

As is typical, actual practice has moved beyond the “official” stance on these issues, as the guidance from professional societies is believed to be “too strict” by some cardiologists and not specific enough by others in the field.  The early adopters are reaping the benefits of these changes in pathways of care.  The problem for most hospitals in making changes such as these in daily practice is physician inertia.  These changes mandate physician education and adoption of new techniques and approaches; careful patient selection, risk stratification, and care management; and procedures in place to be able to successfully manage the new care processes with carefully trained staff.

For several years, cardiology fellows in training have been receiving specific experience and education in the use of transradial techniques.  This has left interventional cardiologists who received their training prior to the inclusion of transradial access in their training programs to seek out other training programs and methods to learn to use this technique competently.  Many vendors of transradial access devices arrange for and provide educational opportunities for interventional cardiologists and cardiac cath lab staff to receive education and training in this technique.


All hospitals should actively seek to improve quality, lower costs and enhance patient experience.  Adapting new, well documented care pathways, such as TRI and SDI, are important strategies in the continuing quest for clinical excellence and the delivery of value-based care.

There are consensus guideline documents available through the SCAI, ACCF and AHA and training programs offered throughout the country by the PCI product vendor community.  Planning, implementing or expanding a transradial access PCI program in your hospital will require some research and education, but the potential benefits in outcomes, patient satisfaction and cost savings are well worth the investment.

If you are interested in learning more about strategies to deal with cost reduction and quality enhancement programs for cardiovascular or other services, please contact CFA at (949) 443-4005 or by e-mail at  


[1] Inclusive of low-risk patients who generally have preserved EF (>30%), no N-STEMI, controlled BP, normal mental status, creatinine <2.5 mg/dl, INR <1.8, does not require prolonged anti-coagulation post-procedure, hemodynamically stable, no allergies to ASA, has not received LMWH or thrombolytic therapy in the past 48-hours.

[2] Accessed through the website a resource for CV management staff and cardiologists seeking up-to-date information on TRI.

[3] Because same-day PCI discharge is not currently the standard of care in the U.S., each hospital program should have detailed inclusion/exclusion criteria in place.  Determining the definition of an appropriate patient requires a combination of what is defined in the literature and what is most appropriate for the individual needs of the specific patient.

CMS Delays Cardiac Bundled Payment Model

Posted by John Meyer, FACHE

Mar 24, 2017 7:42:49 AM

CMS Delays Cardiac Bundle image.jpgThe Centers for Medicare and Medicaid Services announced on March 21st in the Federal Register the following news on the anticipated implementation of the mandatory cardiac bundled payment initiative:

  • Implementation, expected in July 1, 2017, has been delayed three months to October 1, 2017.
  • The publication of the final rule laying out the implementation of Comprehensive Care for Joint Replacement, the cardiac initiative and other bundled payment programs is postponed from March 21 to May 20, 2017.
  • CMS is seeking comments on the “appropriateness of the delay.”
  • The Cardiac Rehabilitation Incentive Payment Model has been postponed.
  • CMS is weighing the delay of implementation of all new bundled payment initiatives even further, until 2018.

Stated reasons for the delay include:

  • Giving more time for comments on pushing back the implementation date (now January 1, 2018) and feedback to better structure the program.
  • Provide adequate time for CMS to undertake new rule-making, comment periods and modification to proposed rules as may be required.
  • Provide additional preparation time for hospitals.
  • Ensure that hospitals have a clear understanding of the rules of participation.
  • Align implementation with the calendar year.

As everyone remembers, the new program was initially presented in April 2016 across 800 hospitals in 67 metropolitan areas, with Medicare proposing to pay providers a single payment to cover all costs associated with a defined episode of care covering 90-days (acute and post-acute).  This program was to be expanded to include heart attacks and coronary artery bypass surgery in 98 randomly-selected metropolitan areas beginning in July 2017 and ending December 31, 2021.  This was to be mandatory, not voluntary.

The Trump administration's move to delay these initiatives raises questions about the future of government efforts to usher healthcare out of fee-for-service operations and into a new age of value-based payment.  Such efforts were a hallmark of healthcare reform under the Obama administration, which set the goal of having half of traditional Medicare dollars go through alternative payment models by 2018.

There continues to be conjecture that mandatory bundling for select cardiac services will never occur ‒ at least on the part of the Federal government.  We will have to wait and see.  CFA believes that bundling will continue to be looked upon as an important payment methodology by both public and (increasingly) private payers, and that the fundamental building blocks of successful bundling need to be addressed by all hospitals in an effort to prepare for the inevitability of an increase in bundling payment models.  These models are complex and far-reaching in scope and will need hospitals to address their efforts towards physician commitment, team-building, care management, cost reduction and post-acute care network development in order to be successful.

Additionally, regardless of the ultimate outcome of bundled payment, the activities and preparations required will not be without reward ‒ the baseline capabilities critical to successful bundling (see will be advantageous in continuing to enhance efficiency and quality of care.

As always, CFA welcomes your comments and suggestions.  Please contact CFA at (949) 443-4005 or by e-mail at

Learn More About MACRA


Why Many Hospital CFOs Are More Optimistic About the Future

Posted by Peter Spiers

Mar 18, 2017 8:03:13 AM

Why Many Hospital CFOs Are More Optimistic About the Future.jpgThe Basis for Renewed Financial Optimism

After more than a decade of paltry economic growth, many CFOs and healthcare sector financial analysts are becoming more bullish on the future of their health services organizations’ financial positions and performance. This is due in part to the changing financial landscape emerging within the US economy.  A number of promising signs and trends1 support this notion:

  • Significant tax reform will most likely be enacted and made retroactive to January 1, 2017
  • $3 trillion increase in the US stock market value over the past 2-3 months
  • New plans/executive action to decrease the overall regulatory burden on US businesses, including the healthcare sector
  • Increased jobs growth and new business start-ups
  • Enactment of a projected $1 trillion US infrastructure bill
  • Increased market-based healthcare reforms will increase access, reduce costs/taxes and regulation
  • New tax and business-friendly environment stimulating repatriation of nearly $1 trillion in wealth from international companies
  • Analysts are predicting 2017-2018 will result in a better investment climate for hospitals/health systems

So, how do any of these factors pertain to increased hospital CFO optimism?  And why would any of this positively impact hospital/health system cardiovascular services?

Potential Impacts on Hospitals/Health Systems

From capital budget support to bolstering operational revenues, hospitals have relied on various types of non-healthcare-related revenue streams to survive and thrive.  Even many of the tax exempt not-for-profit hospitals have – in the tepid economic, high tax, heavily regulated US business environment of the last decade– been operating with the wind not beneath their wings, but blowing against them.  With the steady decline in reimbursement rates from all payer types, and increasing bundled payment, uncompensated care and cost ratios, hospitals require substantial financial support from investment income, cost reduction and other revenue streams.

The anticipated new financial landscape is a welcome change.  For example, in California, and many large metropolitan markets across the country, many hospitals operate in high “at risk,” revenue discounted and Medicaid-heavy environments. They must deal with high levels of uncompensated care, reimbursement erosion and/or over-saturation of competitor hospitals, making sustainable and/or increasing positive margins difficult.

A review of publicly-reported California hospital financial performance data from 2010-2015 showed that 23% to 41% of total revenues for California hospitals came from investment income and other sources2.  California hospitals are not the only ones in the US relying on non-patient care generated revenue to maintain operations.  With the recent positive changes in the economic outlook, CFOs are beginning to feel for the first time, in a long time, the wind may be starting to blow beneath their wings again!

Are New Capital Projects a Possibility?

Many hospital CFOs now sense that their consolidated financial statements will likely improve with a more robust economy, tax relief, expanded investment portfolios and GDP growth above 2%.  A likely net result is that hospitals will be in a better position to develop strategic and other business ventures and grow investment income.  Based on the rate and magnitude of economic growth going forward, and the implementation of some or most of the economic changes discussed above, CFOs will most likely be in better positions financially to develop new clinical programs and services.  Putting long shelved projects back on the to-do list will be a good sign that things are better – with the net result being steadily improving financial portfolios and operating performance for their organizations.

Is New Heart Program Development on the Horizon?

For over a decade, new heart program start-ups or expansions have been declining.  Based on our strategic hospital growth analysis, CFA predicts the beginnings of an uptick in new and/or expanded cardiovascular program development in selected markets.  With early growth likely to begin in late 2017 and early 20183, this will mark the first increase in the development of new cardiac programs in nearly 10 years.

CFA’s business intelligence data and published reporting by other analysts show a minimum of 9-12 states with nearly 30 rural and 20 urban markets which are ripe for new cardiovascular program starts ups and/or expansion4.  Many CEOs with little or no cardiovascular program capability are becoming much more interested in keeping and/or re-directing more of their out-migrating cardiovascular business.

What About Pending Healthcare Reform?

As we post this blog, Dr. Tom Price is busy managing his first major legislative initiative as HHS Secretary:  repealing and replacing the Affordable Care Act.  While the sausage making continues, there are a few predictable changes coming that are, by all accounts, positive for the US economy and the US healthcare sector:  It appears that there will be a steady shift to more market-based, patient-centered and physician-friendly approaches to government oversight and intervention into healthcare access and delivery.

  • Dr. Price’s overall philosophy toward the provision of healthcare is to determine what the government does and doesn’t do well by asking the question, “Is this best for the patient, their families and their healthcare providers?”
  • Secretary Price told Sen. Bob Casey (D-PA) that when it comes to the final version of the MACRA rule, “significant challenges remain with respect to provider burden.”
  • And he expected some changes to the regulation because it creates an “unnecessary extra paperwork burden on hospitals and doctors.”


The shift to reducing government regulation and focusing on simplifying and streamlining the provision of patient care can help decrease unnecessary healthcare costs and increase user satisfaction.  Dr. Price is looking at number of innovative field-tested, patient-centered care models developed by physicians, hospitals and medical groups that are producing positive results. Tort reform, increased insurance competition and the use of new customized insurance models – based on need and consumer choice – are welcome changes to the one-size-fits-all approach of the Affordable Care Act and should reduce premium costs for employers and for younger, healthier populations.

Government healthcare reform and the new focus on decentralizing government control and regulation on healthcare access and delivery is a challenge.  The overall change in the economic landscape and the convergence of demonstrable enthusiasm for robust financial growth in the new administration and the business community creates a positive environment to make these things happen!

As always, CFA invites your comments, suggestions and questions.  For additional information, including strategies for developing new or expanded cardiac services, please call us at 1-949- 443-4005 or send us a confidential email at

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[1] US Economic Outlook 2017, see
[2] California DPH-OSHPD Hospital Financial Report 2010-2015
[3] CFA Internal Analysis 2017
[4] Expansion of Invasive Cardiac Services in the US. Circulation. 2013

New Rationale for Heart and Vascular Services Integration

Posted by Stan Holland, Director, Heart & Vascular Center, Sentara RMH Medical Center, Harrisonburg, VA, and Richard Clark, CFA

Mar 9, 2017 8:00:32 AM


New Rationale for Heart and Vascular Services Integration image.jpgThe integration of Heart and Vascular Services has been an ongoing challenge for the past 15 years or so.  CFA has long promoted the benefits of heart and vascular services alignment, as the advantages far outweigh the time and effort necessary to achieve integration. 

 Now, the inexorable march to true value-based care delivery, coupled with the need for comprehensive and integrated management of patient care that will be demanded by Episodes of Care (EOC) payment models (also see part 2 on EOC and Bundled Pricing), mandates a new focus on Heart and Vascular Service Line integration.  This post examines the issues, approaches, and potential outcomes of successful integration as a proactive solution to the business challenges and care delivery demands facing cardiovascular services providers. 


 In recent years, hospital vascular programs have begun to expand rapidly to address the growing problem of peripheral artery disease (PAD),[i] the availability of new interventional technologies and attractive reimbursement rates.  Vascular disease is a growing problem, affecting 8 to 12 million people in the U.S.  While enticing, the ability of hospitals to take advantage of vascular opportunities has been hindered by many factors:

  • Turf battles between rival specialists (see “Factors Affecting Integration,” below)
  • Personal agendas
  • Historical inattention to the disease
  • Lack of a truly collaborative approach to identifying at-risk patients, intervention and follow-up
  • Lack of physician leadership
  • Lack of appropriate organizational structures to allow for effective program development, business planning and marketing


Clinical Basis for Integration

 Technological advances in non-surgical techniques have accelerated the treatment of PAD – specifically, the advent of percutaneous transluminal angioplasty (PTA), vascular stents and various atherectomy devices.  Of note is the fact that while the use of PTCA and coronary stenting has eclipsed cardiac surgery in volume and rate per population for cardiac disease, PTA/stent volumes and rates have also increased along with vascular surgery volumes and rates.  Additionally, technological advances in diagnosing PAD have begun to replace conventional diagnostic angiography and digital subtraction angiography with computed tomographic angiography.  The use of CTA has progressed rapidly, and where available, has almost completely replaced conventional angiography.


Factors Affecting Integration 

Desirous of expanding their vascular business, many hospitals have become paralyzed by the political turf war that has erupted between vascular surgeons, interventional radiologists, interventional cardiologists and vascular medicine specialists.  This turf battle has arisen largely due to the development of nonsurgical techniques, including PTA and stents.   Historically, interventional radiologists performed most endovascular procedures, then vascular surgeons entered the field, and interventional cardiologists have been adding this capability, including endovascular training as part of interventional cardiology fellowships.  Many believe that no single specialist has all the skills required to perform all procedures, therefore necessitating a more collaborative, and multispecialty approach to vascular services. 

Interventional cardiologists have become leading advocates of their position in the overall treatment of PAD.  They argue that they are best trained and equipped to manage the disease, have interventional skills (characterized by the philosophy that “a vessel is a vessel”), and access to the cath lab where peripheral interventions can be performed using the same fluoroscopy and angiography equipment.  They also differ from the interventional radiologists in that they are not exclusively dependent upon referrals.  No less important is that PAD cases are promising sources of additional practice revenue providing some protection against shrinking cardiac reimbursement.  (Unfortunately, interventional cardiology training programs that have endovascular training typically do not incorporate comprehensive vascular medicine and vascular patient care into their programs.)


Cardiac & Vascular Service Line Integration at Sentara RMH Medical Center (SRMC) 

The ongoing Cardiac and Vascular Services integration at SRMC has resulted in numerous advantages to both the hospital and the involved physician specialists.  At the System level, an overarching structure provides the framework for cardiac and vascular coordination:


System Level

Leadership and OrganizationThe CV Service Line Vice President provides administrative leadership to cardiac and vascular, while a Cardiac Service Line Medical Director and Vascular Service Line Medical Director routinely collaborate to ensure a coordinated approach to physician leadership.  There is also a formal structure of System Committees to coordinate the service lines.

(Note:  The Cardiology Service Line committee structure has been in place longer, so it is more complex; it is organized into geographically regions.  The Vascular Service Line committee structure is organized around anatomical structures.)

Information TechnologyThe Cardiovascular Information Technology Plan reflects system-wide consistency.  This is being developed into a system-wide focus across both services.

(Note:  Ten of twelve hospitals are on EPIC EMR.  Two hospitals have come online in 2016.  This has created opportunities for the “new kids on the block” to influence the eight incumbents.)

Quality ManagementThe overall approach to quality includes Data Registries and System Score Cards.

(Note:  The Cardiac Service Line Score Card is more complex, as influenced by the greater number of registries in the Cardiology & Cardiothoracic Service Lines.  Vascular is adding more modules.)


Hospital Level ‒ In Place

Leadership and OrganizationThe Heart & Vascular Center Director provides administrative leadership to cardiac and vascular, while unified CTS, Cardiology and Vascular Medical Directors meet regularly to ensure a coordinated approach to physician leadership.

LocationHeart & Vascular Services are located adjacent to one another in the Heart & Vascular Center; Heart & Vascular uses the same Interventional Suite and shares the new Hybrid OR.

Quality ManagementCardiac, CTS and Vascular have score cards; Medical Directors share results, successes and opportunities (i.e., documentation).

(Note:  SRMC has an advantage in that the Data team is located on site within the Heart and Vascular Administrative suite.  Three of the four staff have experience in, or still work in, the clinical lab.  This is a real advantage because they understand workflow.  These staff now report to Corporate data team leadership.  This will expand their understanding assuring consistent methodology.)

Physician & Advanced Practice Clinician (APC)[ii] Recruitment & Cross-trainingThe coordinated service line provides opportunities to participate in the recruitment process as well as exploring the sharing of APCs across disciplines in the future.

Multidisciplinary Clinical Services, Patient Care Models

●      Structural Heart/Hybrid OR – Vascular, Cardiology, Cardiothoracic Surgery

●      Pulmonary Embolus Service – Cardiology, Vascular,

●      Mini-Afib Staged procedure – EP (Cardiology), Cardiothoracic Surgery

●      Laser Lead Extraction (later 2017) – EP (Cardiology), Cardiothoracic Surgery


Also at the Hospital level, we are exploring numerous other opportunities for synergy.  Conceptually, this exploration is born out of questions from physicians within the service line asking why are we doing this?  A great question and it must be answered – the why behind the what!


Hospital Level - In Development

Leadership Training for PhysiciansExploring options for providing joint leadership training for current and future medical directors together in the same setting.

Accreditation (ICVAL & ICEAL)PVL and Echo Labs are both accredited; looking at leverage opportunities to share the process & Best Practices.

Continuing Education HoursExploring Staff, Physician and APC opportunities to share resources for continuing education.

Interaction with Hospital Credentials CommitteeReview current and new credentials, provide recommendations and jointly develop credentials for new clinical procedures.

Peer Review The integrated service line will provide subject matter experts and develop an understanding of the process.

Succession PlanningJoint effort to develop 1-3-5-year plan for Physicians, APCs and Heart & Vascular Leaders.

ResourcesProvide joint recommendations to the Capital Allocation Committee, 1-2-3 years; review and approve/recommend FTE and Non-Salary Budgets

Operating EfficiencyLeverage Best practices for efficiency and successful documentation of patient acuity and registry and score card metrics.




For the Hospital and the System, the advantages of an integrated cardiovascular service line are clear from the information provided in the lists above.  For the cardiac and vascular physicians, the advantages of integration are many:

  • The Integrated Service Line’s influence in the Hospital/System is greater than separate service lines (e.g., in the budgeting process, with the Credentials Committee and other Medical Staff Committees, with the C-Suite, etc.).
  • Diagnosis of disease and patient treatment can be enhanced through collegial multidisciplinary approaches.
  • Cross-training and sharing of APCs can mitigate staff shortages.
  • Opportunities for continuing education are enhanced.
  • Practice succession planning and recruitment of physicians and other staff are better organized with greater opportunity for success. 

As you move toward heart and vascular integration in your hospital, and if you encounter resistance from your physicians, these advantages should be presented and explored – they will help your medical staff see a win/win scenario. 

If you are interested in learning more about strategies for heart and vascular integration and/or other programmatic concerns about cardiovascular services, please contact CFA at (949) 443-4005 or by email at 

[i] PAD is a highly prevalent disorder and a frequent marker for systemic atherosclerosis, thus identifying a group of patients at high risk for cardiovascular mortality and morbidity.  Estimates of prevalence run between 8 and 12 million in the U.S., prevalence increasing with age.  Only half of Americans with PAD are symptomatic.  About 25% of patients presenting with coronary artery disease also have PAD.  Although most common in the extremities, PAD also occurs in the carotid arteries, abdominal aorta and renal arteries.  The risk factors for PAD are essentially those of coronary artery disease, with diabetics at 3-4 times the risk of developing the disease than non-diabetics. 

[ii] Physician Assistants, Nurse Practitioners, etc.

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