Low-Volume Cardiac Surgery Program "Excellence"

In a previous blog, CFA asked the question, “Can a low-volume cardiac surgery program be excellent?” (posted November 16, 2016).  CFA estimates, 

through our participation in and review of national proprietary hospital database(s) and a review of states that report hospital cardiovascular volumes and outcomes, there are at a minimum of 300 to as many as 500 heart programs with cardiac surgery volumes of less than 120 cases per year[i].  We have received positive feedback and significant interest on this subject, so we have decided to write a series of articles on the general topic of low-volume cardiac surgery programs and the pursuit of excellence.  This is a first in a series that addresses the general excellence topic.  Future blog posts will continue to investigate the topic and help you understand why it is critical, how it can be successfully addressed, and what the journey to achieving excellence will look like.

There probably isn’t a cardiovascular service line administrator who does not believe that the pursuit of excellence is not one of, if not the most important of her or his goals; both personally, managerially and for their program.  Conceptually inherent in modern management, the term has been so inculcated into healthcare management that it would be hard to dispute its importance.  However, like many “fuzzy” management terms, it can mean nothing, something or everything, depending on your perspective.  What really is “excellence?”  Who defines it for cardiovascular services?  How is it measured?  How does volume influence the equation?  Why is it so conceptually simple, yet ultimately so complex?  And finally, does being “excellent” really make a true difference?  Does excellence actually have a return-on-investment (ROI), or is it more fuzzy thinking or viewed intrinsically by managers as simply the “right thing to do?”

Why Excellence Now?

CFA’s consultants have been addressing the “excellence” question for many years. In the 1990’s, we pioneered a methodology and approach to defining CV centers of excellence when the market in many regions was open to that approach for specialty contracting.  We periodically revisited the question of program volume and quality (not that this issue has or will ever go away!).  We have been called in to diagnosis ailing and low-volume programs and found issues relating to excellence as a foundational cause.  Market dynamics and payer/contracting issues can and certainly will impact program volumes as well.  Much of our personal work philosophy is based on building a high-quality product designed to support the production of excellent clinical results.  It is so fundamental in our work DNA we can all sometimes take it for granted, but we should not.

Recent changes in the evolving national market are causing us to rethink the concept and the practical achievement of excellence.  These changes include the overall decline in cardiac surgery and interventional cardiology procedure volumes, the evolving payer market, the national issue of repealing and replacing existing coverage programs, and other impacts.  Clinical issues relating to the relationship between volume and quality still exist and the volume/quality/outcomes conundrum of whether or not it equals or doesn’t equal excellence is perpetual and should perhaps remain as such, lest one downplay its importance!  Overall, this is a major issue to address, and it can’t be discussed at any length in one sitting, hence our decision to author a series on the subject.

Addressing the Concept of CV Excellence

Here are some of CFA’s thoughts on excellence, relating to general cardiovascular services, just to get the conversation started and on which we intend to embellish and revisit from time-to-time in future postings.

• Who defines excellence? – An excellent question (no pun intended…well, maybe a little).  It seems like today, everybody is in the excellence-definition and validation business, which gives the impression of validating the importance of (or at least the perception of) being excellent in your local marketplace.  Differentiation between two or more alternative providers is the name of the game.  Promoting excellence has two approaches, each focused on a specific target audience:
• The consuming public – Organizations such as Truven Health Analytics, with their Top 50 Cardiac Hospitals, health grades©, Medicare’s Hospital Compare, Consumer Reports Cardiac Surgery Ratings, and so on rate entire programs or critical parts thereof (e.g., mortality rate, cost) intended to impact consumer decisions through transparency.
• Hospitals and clinicians – The Joint Commission with their new Comprehensive Cardiac Center Certification program, individual professional society’s certification programs, and many others evaluate clinical component subprograms (e.g., ACE Accreditation Programs for cardiac cath labs) and focus their specific expertise.  Hospitals can then market a specific service to a targeted population or certify each component part of a program in the hope of presenting a unified brand approach.

• OK, but who “really” defines excellence? – In the near-term past, whenever CFA was asked this question, we had a straightforward answer: “The payer defines excellence.”  The logic seemed faultless. Your program could have every certification and designation of excellence that could be procured from accreditation, clinical societies, or other bodies, it could even be the high volume/low cost leader, but if a payer didn’t “validate” you in the marketplace by granting a center-of-excellence-type contract, you were no more distinguished than any other CV program.  Oversimplified and a bit cynical perhaps, but an argument can be made that this is still valid in many regions and markets today.  For example, if Lowe’s has a CV center-of-excellence agreement with the Cleveland Clinic for cardiac surgery, would anyone dispute the underlying fact that the market just validated The Clinic’s excellence status, by choosing them over a (or all) competitor(s)?
• Why pursue excellence? – Most would initially answer this question with a philosophical or moral-based statement, which would be totally appropriate in a field that is centered on the care of people in need.  From a business perspective, the answer is basically tied to the widely-held belief that “excellence” – however defined or bestowed – is a “state” that, when achieved and documented, can be successfully marketed and thus potentially contributes incremental volume and revenue to the enterprise, all other factors being equal and based solely on the enhancement of customer perception, satisfaction and brand awareness.  Prospective patients vote for excellence by selecting you over your competitor; at least that is the hope and the logic required to commit to targeting the enhancement of excellence in the first place.
• Does excellence have an ROI? – Of course it does, but admittedly, it can be problematic to measure. Excellence has quantitative and qualitative aspects to it.  If the goal of excellence is to produce clinical results that generate incremental volume, then this can be measured over time and factored into the budgetary process and analysis needed to measure ROI.  Typically, for the majority of cases, clinically superior practices and outcomes most often result in shorter lengths of stay and reduced complications and overall resource consumption.  Considerations contributing to an excellent program are multifactorial and interdependent of normal day-to-day operations, as well as ongoing efforts to generate additional business, so isolating the logical consequences of excellence programming would be difficult.  Thus, trying to justify an excellence program based on a positive ROI alone may be a risky proposition.  Given a newfound focus on episodes of care, incorporating downstream revenue (30-, 60- 90+ days from a primary event), is easier than in previous times, but it does require sophisticated data systems.  Many uncontrollable factors could impact any attempts at calculating a valid ROI, including market competitor actions, payer trends, changes in physician provider agreements, and the like.  Most participants in any excellence effort, particularly physicians and other clinicians, will want to commit to such an effort based on an inherent belief that improving patient care and operational effectiveness is a valid endpoint in-and-of-itself.
• Not the endpoint, but the journey! – So, if you committed to excellence, made every effort possible to attain available certifications and accreditation and felt you had achieved the desired goals, and still weren’t singled out for recognition by the payer market, would it have been worth it?  Yes, clearly it would!  Think of the benefits of the journey regardless of the sought-after endpoint.  Building a committed team, putting in the focused efforts, strengthening communication, achieving and maintain your goals over time and the enhanced clinical outcomes for the patients your program cares for has many inherent benefits.  In its broadest definition, excellence can be defined as providing the best possible service, achieving the best possible clinical outcome, and at a fair and reasonable price, all within the overall context of your unique market area of operation.  Achieving that goal on a consistent basis should solidify the hospital’s overall reputation and manage its brand over time.

In an upcoming post, we will dig deeper into this subject and address the multiple factors affecting the development of a Cardiac Surgery Program of Excellence such as the interplay between local and national market dynamics, impact of your program profile, reimbursement issues, operational structure and physician issues.

Implications

CFA does not believe it has to convince any cardiovascular program administrator to actively pursue excellence.  We take that as a given.  However, the pursuit of excellence specifically tied to strategies to enhance low-volume cardiac surgery programs may be a tougher sell – both philosophically and in practical terms.  Why it is done, how it is done and the overall effectiveness of the effort will vary significantly from program to program, market to market and region to region for many reasons we didn’t have time to discuss today but will address in the future.

Remember that all important endeavors take time, commitment and dedication.  However, none of these factors, even taken as a whole, should detract from the overall goal of achieving programmatic excellence.

We will be posting additional articles regarding developing excellence within low-volume cardiac programs in the near future.

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 cfa@charlesfrancassociates.com.

[i] Definitive Health National Hospital Database, 2017