The CFA Perspective

John Meyer, FACHE

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CMS Announces New Voluntary Advanced Bundled Payment Model for Ten Cardiac Clinical Episodes

Posted by John Meyer, FACHE

1/10/18 2:39 PM

CMS announced on January 9, 2018 a new advanced bundled payment model for 29 inpatient and three outpatient clinical episodes.  Included are eight inpatient cardiac episodes and two outpatient cardiac episodes.  After dropping the mandatory Cardiac Bundled Payment Model in 2017, CMS’s Center for Innovation is moving aggressively to test a new iteration for 32 total patient episodes on a voluntary basis.  Here are the facts you need to know.

  • To be known as the Bundled Payment Care Improvement Advanced (BPCI Advanced) model
  • The model is completely voluntary
  • The following inpatient cardiac episodes are included:
    • Acute myocardial infarction
    • Cardiac arrhythmia
    • Cardiac defibrillator
    • Cardiac valve
    • Congestive heart failure
    • Coronary artery bypass graft (CABG)
    • Pacemaker
    • Percutaneous coronary intervention (PCI)
  • The following outpatient cardiac episodes are included:
    • Percutaneous coronary intervention (PCI)
    • Cardiac defibrillator
  • A single retrospective bundled payment and one risk track, with a 90-day clinical episode duration
  • Payment is tied to performance on quality measures
    • Two measures, all-cause hospital readmission rate, and Advance Care Plan, apply to all episodes
    • Five other measures will only apply to select episodes
  • Qualifies as an advanced Alternative Payment Model under the Quality Payment Program of MACRA where providers take financial risk to earn incentive payments
  • Open to both acute care hospitals and physician group practices
  • Preliminary Target Prices provided in advance of the first Performance Period of each Model Year
  • Reconciliation will be semi-annual where CMS will compare the aggregate Medicare Fee-for-Service expenditures (including outlier payments) in a clinical episode against the Target Price for that clinical episode to determine if the participant is eligible to receive either:
    • A payment from CMS (the “upside” risk); or,
    • Is required to pay a repayment amount (the “downside” risk)
  • Participation begins October 1, 2018 and runs to December 31, 2023
  • Applications must be submitted electronically by March 12, 2018 at 11:59 pm EST

For complete information, visit  Included are downloads for the Application Template, Data Request and Attestation Form, Participating Organization List and other relevant information required for participation.

As CFA predicted when the mandatory bundled pricing model was cancelled, we felt certain that CMS would introduce new voluntary models; we just didn’t know it would be this soon, or include so many cardiac episodes including some outpatient episodes.  CFA strongly recommends that all hospitals, regardless of their readiness or inclination to participate, should study the proposed model and review the Application Template in detail to familiarize themselves with this opportunity and its requirements.  Understandably, voluntary participation in risk-taking models qualifies as a significant decision with extremely impactful potential financial and clinical implications.  Make no mistake, this is the way federal payment reform is proceeding; perhaps more rapidly than we ever imagined.

CFA will continue to monitor the roll-out of the BPCI Advanced model and provide updated information and analysis in the coming weeks.

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

Can Low-Volume Cardiac Surgery Programs be Excellent? A 2017 Update

Posted by John Meyer, FACHE

11/10/17 10:17 AM

Low Volume Cardiac Program Excellence Update 2017.jpgIf you follow CFA’s blogs, you hopefully will have read our current and continuing series on low-volume cardiac surgery programs and the challenges they face in the evolving era of value-based healthcare (refer to Low-volume Surgery Programs:  Parts One through Five).  You may also remember our blog post from last year in which we asked the question, “Can Low-Volume Cardiac Surgery Programs be Excellent?” (posted November 15, 2016).  We have received a great deal of response and feedback to this series, indicating that this issue is very much top-of-mind at many American hospitals.  The release of the 2017 IBM Watson Health 50 Top Cardiovascular Hospitals listing published in the November 6 issue of Modern Healthcare focuses our attention on this subject again.

Basically, our position is that low-volume cardiac surgery programs are at increasing risk, and that difficult strategic and operational decision-making needs to take place to successfully address this issue over the long-term.  CFA is poised to post its updated and expanded white paper, Self-Preservation Strategies and Excellence Expectations, in the very near future, to update and share our thinking on this critical subject.

Certainly, we have worked with many low-volume programs over the years that have had excellent outcomes, by any standard measures.  But frankly, success under yesterday’s market conditions was generally easier, even at a lower volume, and today’s environment and the value-driven direction we are heading toward makes it much more difficult.  The “average” low-volume cardiac surgical program may eventually be doomed, but can a program that maintains a low-volume perform well enough over the medium- to long-term to truly succeed and possibly even survive?  Or are they ultimately candidates for consolidation or divestiture?  These may be simple questions; but ones with very complex answers with wide-ranging consequences.

I am sure you are all familiar with the previous year’s Truven Health Analytics’ list of Top 50 Cardiovascular Hospitals in the U.S.  The 2018 list was published in Modern Healthcare, November 6, 2017 under its new banner, IBM Watson Health.  Hospitals make the list[i] by outstanding performance in areas of quality and cost measures applicable to heart attack, heart failure, CABG surgery, and PCI including:

  • Risk-adjusted inpatient mortality rates
  • Complication rates
  • Clinical process measures
  • 30-Day readmission and mortality rates
  • Severity adjusted length of stay
  • Average cost of care
  • 30-Day episode payment for heart attack and heart failure (two new measures for 2018)

In summary, these seven measures focus on cost reduction, best practices, quality outcomes and reimbursement incentives.  Hence the “value play” principle.  What you do not see is case volume criteria. Therefore, by these measures, any program can be excellent regardless of volume.  Yet volume mix is clearly a key factor (i.e., use of risk adjusted scoring).

Top Performers, Despite Low-Volume?

Last year, I looked at just the Community Hospital listing of fifteen hospitals and matched their cardiac surgical volumes for CY 2015, the latest year available, to see if any low-volume hospitals made the list.  The combined volume for CABG and valve surgeries, the vast majority (80+%) of all “cardiac” surgeries, ranged from a hospital with a low of 46 patients to one with a high of almost 850 patients.  Three of the fifteen hospitals were what CFA would define as “low-volume” programs; with 46, 53 and 59 patients respectively.  And yet they made the list of 2017 50 top performing cardiac hospitals, in the Community Hospital category.  By comparison, two “low-volume” hospitals made the 2018 list in the same category with volumes of 100 and 76 cardiac surgeries respectively.  Perhaps the hospital with 100 surgeries is arguably on the “cusp” of low-volume – perhaps not.

By IBM Watson Health’s analyses, a hospital cardiac surgery program that performed as few as 46 surgeries is a top 50 hospital[ii].  By-the-way, congratulations to them, they have defied the conventional wisdom and should be proud of their accomplishment.  They have beaten the odds by consistently tracking, monitoring and improving their clinical and operational performance through a systematic and multidisciplinary process incorporating evidence-based medicine (at least in 2017!).  This proves that it not only can be done, but also argues the case that it must be done by every hospital attempting to stay competitive in an increasingly value-driven market.  Of note is the fact that the three low-volume hospitals from the 2017 list did not make the 2018 top 15 list and the two low-volume hospitals on the 2018 list made the top 15 for the first time.  This would seem to imply that excellence – at least as defined by IBM Watson – is not only challenging to attain initially, but equally or more challenging to sustain over time.

Succeeding at Low-Volume

Succeeding in improving performance to a high level, despite low-volumes, is an important achievement, and will be possible for some providers, but it cannot and should not be considered a virtual guarantee to save a program from the eventual need to seriously consider strategic and organizational options including consolidation or divestiture.  The national trends are too formidable and the market can be unforgiving to even the best intentioned.

CFA estimates that there are somewhere in the neighborhood of 500 hospitals in the U.S. that operate low-volume cardiac surgery programs.  There are about 40 in California alone.  If approximately 30 percent are “Community” hospital programs (the same proportion as in the IBM Watson Top 50 Hospital designation), then there are an estimated 150 U.S. “Community” hospitals that will need to make substantial improvements to their overall cardiac performance to be able to qualify for the “Top Hospital” list, based on IBM Watson’s analyses and their definitions of what constitutes a top hospital.  If five hospitals have done it during the 2017-2018 time-period, then there is at least the opportunity for others to try and be successful.

Focusing on performance and making significant efforts to achieve real progress in the typical cardiac surgery program takes focus, leadership and teamwork.  This means constantly tracking data and assessing their performance to address unnecessary variation, evidence-based best practice, and enhance overall patient experience.  As the average patient becomes more chronically or acutely ill, data generated from comparative databases, such as the Society of Thoracic Surgeons registry, becomes even more important to the ongoing analyses needed to enhance overall performance improvement across the continuum.  CFA believes the demand for achieving a “center of excellence” status can be and, for many, must be a go-forward strategy to successfully compete in the cardiovascular marketplace.


In conclusion, low-volume cardiac surgical programs can be top performers in quality and cost measures – but they are the exception, rather than the rule.  To be the exception takes a commitment to extraordinary vision, leadership, clinical expertise, 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. All the while recognizing that ultimate long-term success for the institution as a whole may lead inevitably to consolidation or divestiture of their cardiac surgery program simply due to the changing health care delivery and insurance 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   Also, watch for our new, updated white paper, Low-Volume Cardiac Surgery Programs:  Grow, Consolidate or Divest?  Self-Preservation Strategies and Excellence Expectations in the near future.

CFA always appreciates your feedback and comments.

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[i] In three categories:  Teaching Hospitals with CV Residency, Teaching Hospitals without CV Residency, and Community Hospitals.

[ii] Recognize that this opinion is not informed by the specific mitigating local circumstances.  There are many strategic and practical reasons a hospital would want to offer a low-volume program.  In some areas of the country, issues of local access, travel times and/or sole provider status may be legitimate mitigating factors.

Fifth in a Series: “Unwinding” a Low-Volume Cardiac Surgery Program

Posted by John Meyer, FACHE

10/27/17 6:00 AM

In our continuing series on low-volume cardiac surgery program issues and strategies, we thought it would be beneficial to present a conceptually simple and straightforward methodology and approach to “unwinding” a program should that be the decision of hospital management and clinicians.  Having conducted this process with clients on occasion, it represents a way to comprehensively prepare for and efficiently and effectively divest a cardiac surgery program, with special emphasis on the operational implications inherent in such an endeavor.

Assuming that a decision has been made to stop providing cardiac surgery either altogether or through affiliation and/or consolidation with another clinical provider (please see our blog on the consolidation issue here), it is important that the implications of such an action be fully considered and systematic steps be taken to both lessen the potential negative impact on the organization and compensate for this by solidifying other aspects of the overall cardiovascular program.  In many cases, this “compensation” will involve (depending upon the specific state) receiving licensure or certification to offer PCI without on-site cardiac surgery.  In California, this can involve a lengthy and somewhat complex application and certification process, and includes designating a referral hospital for cardiac surgical transfers, but each state situation will vary.  The process we have successfully used encompasses three major steps (refer to graphic) inclusive of a number of logical component parts, as summarized briefly below.

Step One A:  Unwind Team Formation and Process Presentation

 The first step consists of the appointment of an Executive Steering Group (ESG) to oversee the process and approve all necessary actions required to initiate the unwinding.  An Impact Analysis (IA also Step 1) needs to be conducted and an Unwind Process (UP also Step 2) designed.  The IA is designed to identify all of the relevant positive and negative impacts such an action will cause, and consideration given to consequences and action required to mitigate these consequences.  Additionally, a Team Point Person will need to be identified and selected.

Step One B:  Unwind Process/Team Point Person Selected

The IA designed in Step One A is initiated in Step One B.  The IA is designed to identify all of the relevant positive and negative impacts such an unwind action will cause, and consideration given to consequences and action required to mitigate these consequences as may be required.  Upon initiation, and as needed, unintended consequences need to be identified in real time and presented to the ESG for prompt resolution through the designated Team Point Person.  An important factor is the identification of long lead-time items, such as necessary changes in Policies and Procedures (P&Ps), which must match eventual operating conditions (e.g., PCI going forward without on-site surgery) with revised P&Ps.  Other long-lead time items might include:

  • Certification for PCI without on-site surgery (which in California for example, represents a twelve plus month process).
  • Notification of the cardiac surgical group and consideration of all relevant contractual issues.
  • Notification and planning for operating room, recovery areas, and cardiac cath lab staffs, including contingency planning as may be required.
  • Notification and discussions with county/city emergency medical service and emergency transport providers relevant to STEMI receiving center designation, referral hospital transfer protocols, and the like.

All impacts need to be identified and a plan put in place to mitigate these impacts through a systematic process that specifies identified actions, responsible parties, timeframes required and resources needed.  At the conclusion of the Plan development, we strongly recommend it be reviewed and approved by the ESG so all affected parties are informed and the planned-for actions are sufficiently transparent.

Step Two:  Unwind Plan Roll-Out

Step Two consists of the roll-out of the Unwind Plan (UP).  CFA typically utilizes a project tracking system (Project Tracker) consisting of a Gantt-chart customized with all identified tasks, task assignments, due dates and other relevant information so that project management can be handled efficiently and effectively.  After reviewing all assignments with the project team membership, the Project Tracker is approved by the ESG and work initiated.  Any required changes in licensing and/or certification will be coordinated with the state licensing bureau and sequenced with the Unwind Plan.  For example, under typical circumstances, application for certification for PCI without on-site surgery (and thus discontinuation of cardiac surgery) would come when the Application process is complete and certification approved.  Local circumstances and state regulation will dictate the timing and notification of discontinuation and certification or approval of substitute services as needed.  Sequencing of “go-live” dates and or “discontinuation” dates will be part of the UP.


Low-volume cardiac surgery programs are challenging in today’s competitive environment.  Hospitals that have gone through the process of evaluating their options, ranging from investment in program development to divestiture or closure, and have decided on the latter strategy, are urged to engage in a systematic and planned process to unwind the cardiac surgery service.  Cardiac surgery is impactful to both the overall hospital and the cardiovascular service line, and must be carefully managed, even if that management means unwinding the program.

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

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Fourth in a Series: Low-Volume Cardiac Surgery Programs – The “Leakage” Issue

Posted by John Meyer, FACHE

10/10/17 6:00 AM

Fourth in a Series Low-Volume Cardiac Surgery Programs – The “Leakage” Issue.jpgWe have written extensively on the issue of low-volume cardiac surgery and the challenges faced by these programs in today’s competitive environment.  There are many options available to these programs to boost their volume, ranging from reinvestment in program development efforts all the way to divestiture or closure if all else fails.  For hospitals that commit to keeping their low-volume program both operational and thriving (please refer to Can Low Volume Cardiac Surgery Programs be Excellent? and Low-Volume Cardiac Surgery “Excellence”), it is important to appropriately analyze your unique circumstances and opportunities, both to understand the reasons for non-optimal volume, and to ascertain reasonable potentials to increase volumes to appropriate levels in the search for optimal program performance and perhaps, its continued existence.  While there are many potential program-specific as well as underlying market conditions that contribute to volume achievement, let’s talk about the concept of market “leakage.”

The Definition of Market “Leakage”

In an attempt for hospitals to successfully address the low-volume issue, one of the many strategies that can be applied in these situations requires analyzing and addressing the “leakage” issue.  Leakage can be defined as the difference between the size of the market and a hospital’s share of that market.  If a hospital’s market produced 100 cardiac surgeries in a specific year, and its share of that same market is 78, or 78 percent, then 22 patients, or 22 percent went to another provider (either in- or out-of-the-market), or “leaked” from the hospital’s market and potential share.  Assuming the overall size of the market is reasonable, and there is additional market share to be had, trying to increase market share is a reasonable growth strategy.  Note that if there are only 75 to 100 total cases in a given total market, and two hospitals are competing over the same market, then neither program will ever attain sufficient market share to reach moderate to high-volume status. One of these two hospitals probably needs to divest their program.  It is important to stress that leakage can be external – originating in the marketplace outside the hospital system entirely, or internal to the hospital system itself.  Realistically, internal leakage is the more critical priority as it is under the direct control (or at least influence) of the hospital and its medical staff.

Understanding Market Leakage

Understanding the underlying reasons behind leakage and basing any development strategies on a thorough analysis of your situation is critical.  That being said, it is often complex, information-poor and multi-factorial, challenging the hospital to understand the true reasons behind its market position and what changes may be necessary to address any underlying issues.  Here are a few thoughts about leakage.

  • Understanding the issue begins with information.  Acquiring appropriate, accurate and timely market share data is critical to understanding the market.  State-specific mandated databases, commercial databases, Medicare-only databases or other sources can be used – each with pros and cons.  Our experience emphasizes the criticality of defining cardiac surgery appropriately.  (Please see Second in a Series: Low-Volume Cardiac Surgery Programs – Looking “Behind” the Numbers.)  Lumping and splitting within the broad category of cardiac surgery can get you in trouble and suggest inferences that are misleading.  For example, some canned databases define cardiac surgery as one broad category, which negates the real differences in market size, physician and program capabilities (and thus market share) between CABG and valve surgery.  Knowing how many patients go to what hospital for what specific surgical procedure serves as the necessary basis for critical analyses.
  • Recognize the legitimacy of some leakage.  There are, what I would call legitimate clinical and nonclinical reasons for some leakage.  The two most prevalent and logically justifiable are based on technology and program capability and managed care restrictions or exclusive contracting situations.  Here are some examples:
    • If your hospital cannot meet the minimum volume/quality standards to provide a specific service, such as endovascular valve replacement, patients from your market area should legitimately be referred to another provider who can meet these specific clinical needs and outcome standards.
    • If a major employer in your market has an exclusive center-of-excellence-type agreement with, say, the Cleveland Clinic, then eligible patients will bypass your hospital and go there, no matter what the local hospital’s capabilities may be.
    • If your hospital lacks a specific cardiac physician subspecialty (e.g., cardiac valve repair vs. replacement capabilities).

Do not forget that achieving 100 percent market share for any clinical service is unrealistic under almost all market circumstances.

  • Analyze your hospital’s (and other’s) true capabilities.  Once you know who went where and for what, you can ask the question, “Why did they go there and not stay here and come to our hospital.”  Part of that answer is program capabilities and reputation.  A program assessment will need to ascertain relative strengths and weakness, including service offerings, physician staffing capabilities, overall performance (costs position, quality outcomes, patient experience, etc.), and other factors.   Reputation in the market is best assessed with community surveys.  Both activities are often best left to an independent third-party content expert.
  • What is the competition doing?  Once you understand your internal capabilities and your relative strengths and weaknesses, you can assess the competition in a similar fashion.  All hospital’s function within a competitive milieu unless they are sole community providers.  Understanding the competition is not easy, but it is critical to assessing leakage.  Interviewing physicians, major payers, large employers and other providers can often provide insight into you (and your competitor) hospital’s capabilities and reputation.  
  • Do not forget to analyze referral sources.  While it seems self-evident, virtually all cardiac surgery patients are referred by cardiologists.  They are the basis for any program volume.  Interviewing cardiologists (as well as key referring primary care physicians who are familiar with the referral environment) can often pinpoint issues specific to “internal” leakage.  The number and subspecialty of local cardiologists plays an important part in the volume of referrals.  If a program gains or loses cardiologists in a specific subspecialty, logically, referrals to cardiac surgeons may fluctuate.  Additionally, referrals from cardiologist to cardiac surgeon may be based on clinical issues (competency, sub- specialization, outcomes) as well as non-clinical issues such as personality, communication, availability/timeliness of consults, and a host of others – some of which can be both challenging to identify and address.  Realistically, employed versus independent physicians do not necessarily solve the overall leakage program by corporate requests to keep patients within the hospital’s network; internal leakage is more pervasive than some imagine.    
  • Multifactorial interactions. Internal or external leakage is typically not caused by a single issue, but is multifactorial and interactive, with multiple issues that will need to be diagnosed and treated.


Successfully addressing market leakage can be seen as an issue requiring both appropriate program diagnosis and definitive treatment.  For external leakage, appropriate information and assessment can size the market and help define the issue of its provider market shares, composition, competitor advantages and disadvantages and the patient’s ultimate disposition.  Internal leakage can be assessed by program capabilities and deficits, cardiac physician subspecialization, overall staff capabilities and referral patterns.  Realistically, each of these interdependent factors can be responsible for some portion of the overall leakage equation.  Careful and comprehensive analysis is called for and definitive action, no matter how problematic, challenging and potentially requiring an extensive time commitment, will need to take place to maximize program potential, development and success in a specific market.

Low-volume cardiac surgery programs cannot be “rehabilitated” by solving any leakage problem in a vacuum, but within the overall context of the market, can be a vital part of successfully addressing a going-forward strategy.

If you are interested in learning more about strategies to deal with your low-volume cardiac surgery program and a program assessment for cardiovascular services, please contact CFA at (949) 443-4005 or by e-mail at

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Topics: low volume cardiac surgery programs

Third in a Series:  Low-Volume Cardiac Surgery Programs as Centers of Excellence

Posted by John Meyer, FACHE

9/8/17 6:00 AM

In our continuing series on low-volume cardiac surgery programs, we now incorporate the Center of Excellence (COE) concept into our discussions.  We previously posted a blog discussing this topic in a broad sense (see Can Low-Volume Cardiac Surgery Programs be Excellent? posted November 16, 2016), in which we discussed the challenge of low-volume surgical programs.  In this blog we discussed the question of whether or not a low-volume program could be excellent, and concluded that it is possible, witnessed by the fact that a number of low-volume cardiac surgery programs made the 2017 Truven Health Analytics’ Top 50 Cardiovascular Hospitals in the U.S., in six broad areas of quality and cost measures applicable to CABG surgery.

In an effort to help those estimated 500 or so low-volume cardiac surgery programs that may struggle to improve their performance despite low volumes, we applied CFA’s Center of Excellence (COE) criteria[1] specifically to the cardiac surgery service within a hospital CV service line.  This list is in summary form, but is meant to provide the reader with more comprehensive characteristics of a COE beyond the obvious top-of-mind attribute of high quality clinical outcomes.  Yes, that is fundamentally required, but there are several other clinical and programmatic characteristics that should be addressed to achieve true COE status.  Hopefully, we have captured the essence in the list to follow.

Here is our listing of the characteristics of a low-volume cardiac surgery program (always to be considered within the context of a comprehensive cardiovascular program of excellence).  We urge the reader to critically apply these criteria to their own program and see how your program stacks up against the this set of ideal program characteristics.

COE Characteristics for Low-Volume Surgery Programs

  • Corporate philosophy and culture supportive of overall performance excellence; goals are established and resources appropriately allocated to support performance objectives and all administrative staff is held accountable for specified performance.
  • In an evolving marketplace, corporate philosophy encourages the need to compete directly and transparently on the basis of quality outcomes, innovative care provision, organizational capabilities, cost and pricing.
  • An appropriate organizational and managerial structure is in place to plan, develop and implement operating objectives that fosters and rewards accountability, stakeholder input, innovation and creativity.  An appropriate management team, led by a cardiovascular service line administrator, is in place and tasked with all aspects of service line operations to maximize performance.  Physicians are integrated into the management structure, and as medical directors of subspecialty services.
  • Rigorous performance improvement culture and ongoing activities focus on achieving a high level of clinical quality outcomes for all patients, regardless of volumes.  Best practices (in the form of guidelines, protocols and algorithms) are incorporated into care provision and patient appropriateness criteria and risk assessment is rigorously applied.  Inappropriate surgical candidates are systematically referred elsewhere.  Transparency is promoted; key metrics for outcomes, pricing and other important information are publically available.
  1. Participate in the Society of Thoracic Surgeons (STS) National Database and the American College of Cardiology (ACC) National Cardiovascular Data Registry – NCDR® as a means for the hospital to routinely measure its current performance against peer hospital metrics and identify issues for immediate and decisive action.
  2. Work to achieve The Joint Commission’s Comprehensive Cardiac Center (CCC) Certification status for CABG Service and/or Valve Replacement/Repair Service (as one of ten possible service requirements for Program Certification).[2]

We will have more to say about the specific subject of cardiovascular program performance improvement in an upcoming blog.

  • Surgeon(s) and cardiologist(s) that anchor and provide patient care for the program consistently produce high quality clinical outcomes measured against key benchmarks for peer hospitals, regardless of challenging volumes.  Rigorous consensus-based standards are followed, including appropriateness criteria, risk-assessment, clinical outcomes, readmission rates, and cost per case, among others.
  • Key physicians are aligned and integrated into the overall health system, hospital and service-line management/operational structure, including performance improvement activities, defined management role, incentive compensation programs, adoption of best practices, current research/technologies and innovations, and are communicative and collaborative with all team disciplines.
  • Cost management is ongoing, with high-cost drivers identified and subjected to rigorous cost reduction.  Specific low-volume service components (i.e., cardiac surgery) that may be “unprofitable” are consistently subjected to an ongoing cost management focus.  Cost/price per case is highly competitive compared to local/regional benchmarks.  Episodes of care have been defined and pricing/costing established across the continuum for potential bundled pricing or other financing/care innovations.  Although it appears CMS may cancel the planned cardiac bundled pricing initiatives (see our blog from August 14, 2017), other payers have developed similar, innovative contracting models.  Physicians actively participate in cost containment and are appropriately incentivized to enhance specific or overall financial performance.
  • Existing infrastructure, inclusive of technology, facilities, information and supportive systems and staffing, is optimized to promote ongoing activities in the most efficient and effective manner possible.
  1. Clinical technology is state-of-the-art designed and operated to optimize functionality, meet specific clinical needs and optimally match patient utilization volumes.
  2. Facilities are modern, patient-friendly, easy to use, an appropriate mix of in- and outpatient, and located geographically to maximize access and patient experience.
  3. Information systems, including EHR, PACS, CVIS, proprietary/public comparative databases, benchmarking, data-mining, finance and other requirements, are state-of-the-art, integrated and appropriately staffed by experienced personnel.
  4. Clinical program staff is highly knowledgeable, experienced, collaborative, team-oriented, and understand their role in providing excellence and optimizing patient experience.  Surgical, Cardiac Cath Lab, Noninvasive Diagnostic and other support teams are highly experienced, optimally deployed and effectively compensated.  Retention is high and registry usage minimized.
  • Last, but certainly not less important, the patient’s experience at your program – the sum total of the patient’s healthcare experience – is prioritized and aggressively managed by all members of the team.  


Low-volume cardiac surgery programs are increasingly common and ultimately challenged to meet or exceed excellence expectations for self-preservation.  Some will go beyond mere self-preservation and strive for (and achieve) excellence.  At the same time, these hospitals must recognize that ultimate, long-term preservation of their program may lead to the need for focused program development, or as a last resort, ultimate 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.

CFA will be posting additional articles regarding developing excellence within low-volume cardiac programs as part of our ongoing series in the near future.

As always, CFA invites your comments, suggestions and questions.  If you are interested in learning more about strategies to deal with low-volume cardiac surgery programs and programmatic assessment for cardiovascular services, please contact CFA at (949) 443-4005 or by e-mail at

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[1] CFA will be posting its updated Characteristics of a Cardiovascular Center of Excellence in the near future.  This will be a comprehensive look at the ten characteristics that define a “true” CV COE.
[2] See

Topics: low volume cardiac surgery programs