10 Ways to Improve Your Hospital's Heart Program

A great cardiac program can boost patient volume, improve your hospital's reputation and significantly increase revenue. Here five cardiology program experts — three from the hospitals ranked as having top five heart programs by U.S. News & World Report — offer advice on how to build a great heart care program.

1. Appoint great leaders. Bobbi Daniels, MD, CEO of University of Minnesota Physicians, says the most important thing in a great cardiology program is outstanding hospital and physician leadership. "Our cardiology leader has a large breadth of experience, and he's the executive medical director of the entire clinical service. He has business experience and he's a no-nonsense manager who really demands perfection and focuses on both clinical and financial outcomes," she says. She adds the cardiology leader is teamed up with a hospital leader who directs the cardiology service line. By having those two forces — clinical and administrative — present in your cardiology program leadership, you can involve clinical staff and administrative staff in providing quality care and cutting costs down to the front line. "A lot of outcomes that have to occur are very dependent on who's providing that service," she says. "That can be anyone from the front desk to the billing person, so the leaders have to be able to get the complete buy-in of everyone who contributes to patient care."

She says great leadership means setting clear expectations that can be tracked through measurable outcomes. When physicians, nurses and staff members submit reports on their progress, the cardiology leaders should look at the results and make a tangible plan to improve. "When people don't meet expectations, they need to know your leaders will be invested in solving those problems," Dr. Daniels says. "Just saying, 'Why didn't you meet these outcomes?' is not enough. You need to be willing to redesign processes, develop new care models and use those to overcome shortcomings."

2. Combine government-recommended quality measures with measures that serve your specific community. Dr. Daniels says when hospitals track quality, they should focus both on the publicly displayed CMS guidelines and the measures that make sense for their local market. Once the hospital has tracked data on quality outcomes over time, administrators can look at the results to determine which issues are most pressing for cardiology program patients. Maybe the hospital is suffering from high readmission rates because patients are not instructed in proper post-discharge care. "Leaders need to look at the quality measures physicians feel are critical for patient care in that particular program," she says.

3. Choose a payment model that incents physicians to perform better. There are various models of compensation that can incent good behavior by physicians, including distributing compensation by the physician group, employing physicians and basing a portion of compensation on meeting quality outcomes. These three options are not mutually exclusive — for example, Massachusetts General Hospital uses pay-for-performance and employs its physicians — but rather are all good ideas for encouraging quality patient care.

Compensation distributed by the cardiology group: The University of Minnesota Physicians' cardiology service line lets its two cardiology groups distribute the money received through a particular fee schedule as the group sees fit. This way, the people in charge of monetary distribution are those on the front lines of heart care. "The leaders are still held accountable to make sure call is covered, productivity standards are met and patient needs are met," Dr. Daniels says. "But in cardiology, you may have some people who are predominantly doing clinic visits, and the [lower] revenue they generate may not reflect their value to the overall program." She says the cardiologists are in the best position to know how their colleagues should be compensated. Conflicts over compensation can also be handled within the group. "Cardiologists want to control their environment and their destiny, and the more they're allowed to participate in how compensation is distributed, the more they will be a valued and engaged partner," she says.

Employed physicians: Since its inception, Cleveland Clinic has refused to pay its physicians on a fee-for-service basis. Instead, every physician is compensated 100 percent with a pre-determined salary rather than a combination of salary plus incentives. Steve Nissen, MD, chairman of cardiovascular medicine at Cleveland Clinic's Heart and Vascular Institute, says the policy prevents "turf wars" between physicians and ensures that quality patient care — not financial benefit — is the top priority for every provider. "It's a very liberating environment because it means if you have to take more time with a patient, you take more time," he says. "It's about quality rather than quantity. Rushing patients through and doing more procedures does not enhance the remuneration received by our physicians."
Employing physicians also means physicians don't hesitate to refer a patient to a colleague. "If you go into [other institutions], often the interventional cardiologists and the cardiac surgeons are at odds," he says. "That's not the case here. You can't do what's best for the patient if you're protecting your turf. You have to be willing to say, 'Somebody else is better equipped to get a better outcome.'"

Compensation based on quality outcomes: At Massachusetts General Hospital, physicians have been compensated based partly on pay-for-performance for the last five years. G. William Dec, chief of cardiology and director of the MGH Heart Center, says the hospital has achieved great outcomes by implementing several aggressive campaigns every year to improve a certain facet of clinical care. A few years ago, the hospital incented physician groups to improve hand-washing by giving a collective incentive to each group if its incidence of hand-washing rose above 85 percent. "Based on feedback from physicians and nurses, that's been very successful," Dr. Dec says. "I've been a visiting professor and made rounds at some very famous places, and I can't count the number of times I've walked into a patient room and the entire team walks in and doesn't wash their hands. At MGH, it's just been hammered into our heads. We all know it's the right thing to do, but providing an incentive is important to getting the process started."

He says instituting pay-for-performance can help improve the reputation of a big academic medical center. "There's this idea that academic medical centers are big black boxes where patients get sent in, and the doctors in the community never hear what happens," Dr. Dec says. "I think that by tracking these kinds of things and making them performance standards, you can change your practices and that perception."

4. Organize your teams by specialty. One way to facilitate state-of-the-art care and reduce mortality rates is to organize your physicians according to heart care specialty, Dr. Dec says. MGH's heart care program is organized into 11 disease-specific specialty areas, including arrhythmia management, heart failure, hypertrophic cardiomyopathy, coronary artery disease and other illnesses. Those 11 groups are guided by physician champions, nursing leaders, cardiac imaging leaders and cardiologist and surgeon leaders, and they meet regularly to discuss clinical issues and strategic planning. The 11 groups, while somewhat separate in function, are all housed underneath the heart center steering committee that decides strategic direction for the overall heart program. "When you have these collaborative teams where people really specialize in a particular area, and some surgeons do a lot of bypass surgery and some surgeons work on thoracic aortic disease, you have a group of people with a very high level of experience who know what to do when things go wrong."

5. Build a structured process for deciding which technologies to invest in. Dr. Dec says up until recently, physicians at MGH worked with different companies and brought in new technology that sometimes competed with existing technology. Now the hospital is trying to take a more critical approach to adding new procedures and new technologies by appointing a committee that reviews the cost, potential benefits and implications of each suggested addition. "These are often very large investments, like getting a surgical robot for the OR or getting a new valve program," says Dr. Dec. "If we're considering a new procedure, we think about how many we could afford to do, how much time it will take, whether it will displace other services and what tests would not be paid for based on insurance percentages."

James T. Willerson, MD, president of Texas Heart Institute in Houston, says the heart institute works with companies to develop devices with potential for use in heart and vascular disease. "If a company has developed something that we want to use, we tell them we want to be a partner with them for the development and help make the product constantly better," he says. He says the institute also promotes physician-led research because physicians are so in tune with the needs of their patients. "Physician-led research translates to things that are the most important to the patient," he says. "Those are the things that have a direct effect at the patient's bedside."

6. Review every single patient death. According to U.S. News & World Report, mortality rate is used to rank the best heart centers in the nation. Though the top-ranked heart centers are also judged on their willingness to accept difficult cases — and lots of them — they are also expected to keep mortality rates low. With one of the highest patient severity levels in the country at 7.2 in 2009, Cleveland Clinic impressively manages to keep mortality rates for cardiac surgery patients low at 2.7 percent. Dr. Nissen attributes this accomplishment to the Clinic's heart institute's strict policy about reviewing patient deaths. "The purpose of each [quality review] is to understand if there was anything we could have done better or differently. What can we learn from the loss of the patient?" he says.

The institute could game the system, he says, by accepting easy cases to improve mortality rates. But it doesn't. The patients operated on at the institute are "among the sickest of the sick." The trick to accepting difficult cases and maintaining low mortality rates is having consistent policies in place to educate physicians on the routine for every procedure. Every procedure has an accepted set of policies associated with it, and every action is documented and measured to determine where problems lie. "Does that mean every single patient has a great outcome? No," Dr. Nissen says. "But we always try to learn something from our successes and our failures, and we review [both types of] cases."

7. Eliminate unnecessary transitions between providers. When ranking the best heart hospitals in America, U.S. News & World Report prioritizes a high volume of cases as well as high levels of patient satisfaction. Those two factors might seem at odds with each other, since more patients presumably means less time spent with each. However, Dr. Dec says MGH deals with its high volume of patients by doing a careful evaluation of each patient before sending him or her to a provider. "For new patients, we have an outpatient access office, where a few nurses talk to the patient and the physician about what type of cardiologist or surgeon the patient needs to see," he says. "We avoid redundant work-ups, so while the patient may have to wait for an appointment, the physician will be the right person [for their condition]." He says when the patient sees the right specialist in his or her first appointment, the hospital eliminates time spent transitioning the patient from a general cardiologist to another provider.

8. Track your percentage of new patients and try to increase it. Dr. Dec says MGH keeps track of the percentage of new patients rather than follow-ups for each physician group and each individual physician. "We are challenged to keep open slots for new patients, and we'd like to start doing 30 to 40 percent new patients," he says. He says the difficulty in keeping new patient volume high is that people who come to the hospital for a cardiac service and have a good experience may not want to return to their original community physician. "There's a tremendous amount of loyalty and they want to come back for their lifetime," he says. "You have to help move that transition because a lot of that care can be done by physicians in the community quite well. The challenge is trying to migrate people after the procedure."

9. Promote good relationships with community providers and other hospitals.
If your cardiac program has good relationships with referring physicians in the local community, you can guarantee a steady stream of patient volume. Especially if you serve as a regional referral center for several hospitals without robust cardiac programs, your hospital can provide a great resource to remote communities and receive generous referrals as a result.

Julie Thompson, the STEMI coordinator at Theda Care health system, says the health system has improved relationships with community hospitals by reducing the time it takes to identify patients as having a STEMI heart attack and route them to the appropriate provider. "If a rural hospital sends a patient to us, we can identify through our EMS service that they're having a STEMI heart attack in their living room, and by the time their family drives to our hospital to be with them, they're already tucked in bed and recovering," she says. Improving early identification of heart conditions can increase the patient volume you receive from remote hospitals because the hospitals know their patients will be handled well.

Your hospital can build good relationships with community providers by asking physicians to reach out to local physicians and offer your services. "Many physicians in the greater New England community have established personal relationships with our staff, and there are a lot of really tight relationships between our long-term cardiologists and referring doctors in the community," Dr. Dec says. "Those kinds of relationships are just nurtured by keeping in touch with the community."

10. Promote collaboration between nurses, physicians and administration. The U.S. News & World Report rankings for heart care are partly based on a hospital's nursing standards. Nearly three-fourths of the ranked facilities — including the Cleveland Clinic and Massachusetts General Hospital — are recognized by the American Nurses Credentialing Center as "Nurse Magnet" hospitals for high-quality nursing care, an honor awarded to only one in 15 U.S. hospitals.

Dr. Dec says MGH encourages nurse leadership by appointing the heart care nursing director as one of the senior vice presidents of the hospital. "She has a tremendous amount of influence about decision-making and where resources are put and how staffing is done," he says. "She is at most senior leadership meetings emphasizing the importance of nursing." He says appointing strong nurse leaders — and encouraging lower-level nurses to work toward leadership positions — will emphasize the importance of nurses to your heart care program. He adds MGH has an active program through the Knight Foundation that encourages nursing leadership and nursing research. "If there's a particular look at changing the way discharge is done on one of our cardiac floors, the nurse leader for the care team brings a whole cadre of nurses to talk about the nitty gritty and explain where delays exist," he says.

Dr. Nissen says Cleveland Clinic also encourages nurses to get involved with important issues and take on leadership roles. Instead of adhering to a traditional hierarchy where the physician knows best, the Heart & Vascular Institute encourages nurses to speak up when they see a problem. "If you have a mutual respectful relationship with the nursing staff, it makes an enormous difference," he says. "Occasionally a nurse will complain that a physician is [treating a nurse poorly], and I call them in and say, 'That's not how it works here.' We give our nurses a seat at the table." He says this policy attracts the best nurses in the country, and those that work at the Clinic are happy with their jobs.

Contact Rachel Fields at rachel@beckersasc.com.

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