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

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.  

Conclusion

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 cfa@charlesfrancassociates.com.

Footnotes

[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 https://www.jointcommission.org/certification/comprehensive_cardiac_center_certification.aspx