They don't miss a beat

Imagine how much simpler operating room life would be if all surgeons doing a particular procedure agreed on exactly how to do it and what instruments and supplies to do it with. Imagine how much less time it would take to train nurses and other staff, how much less effort they'd spend trying to remember which surgeon likes what type of suture, and how much less trouble it would be to purchase and manage supplies.

Or stop imagining and pay a call on Venice (Fla.) Regional Medical Center, where the two cardiac surgeons have standardized their practices to the point where OR nurses don't even have to know which of them is doing a procedure. Not only is life simpler, but their surgical outcomes have helped put the 274-bed hospital on Thomson Reuters' list of top cardiovascular hospitals for the fifth year in a row.

“We don't aim for the benchmark,” says cardiovascular surgeon Jonathan Fong. “Our goal is to be significantly better than the benchmark.”

Download the list of hospitals, other charts (PDFs)

Venice is one of half a dozen Florida hospitals whose heart surgeons and cardiac anesthesiologists are provided and trained by the Ocala (Fla.) Heart and Vascular Institute, which subscribes to the “modify, simplify, apply” philosophy developed by pioneering heart surgeon Denton Cooley, founder of the Texas Heart Institute in Houston. All of its personnel do only cardiovascular procedures, they work closely with the cardiologists on staff at the host hospital, and they all adhere to uniform surgical techniques.

There's a certain amount of what Fong calls “style drift” because the Heart Institute's sites are far flung and its surgeons' earlier habits sometimes reassert themselves after a while, but he says that as surgeons deviate, their outcomes suffer commensurately. And the unified surgical process, which results in shorter operating times, fewer complications and shorter lengths of stay, is a strong selling point for Ocala's program.

Fong says the problem tends to self-correct, as those who drift from the norm are unable to reproduce the results of the other physicians. "We have had to bring the results to their attention and allow them time to adjust," Fong says in an e-mail. "If they are unable to, we have asked them to seek other employment opportunities."

“Given their experience with other surgical subspecialties, administrators see that there is a value to uniformity,” Fong adds.

Cardiovascular care nationwide has gotten steadily better over the 12 years that Thomson Reuters has been analyzing Medicare data to come up with the 100 Top cardiovascular hospitals. The differences between the 100 benchmark hospitals and the other hospitals in their peer groups are narrower than they used to be. As a result, it's harder to achieve uniquely high performance. This year, for the first time, the company has limited the list to 50 winners to highlight providers that are truly leading the way. Read more about the methodology (PDF)

“It makes the award much more meaningful,” says Jean Chenoweth, senior vice president of performance improvement at Thomson Reuters.

If all hospitals achieved the same performance as the 50 top cardiovascular hospitals, Thomson Reuters projects that 7,543 more lives could be saved annually, 11,751 additional patients could be complication-free and nearly $910 million could be saved.

For example, the top hospitals' median mortality rate for coronary artery bypass grafts was more than a third lower than the median for all the hospitals in the study, and their complication rate was 11% lower. The top hospitals' median mortality rate for heart failure was 16% lower than the median for all hospitals, and their complication rate was 21% lower.

Pomona (Calif.) Valley Hospital Medical Center made the list for the first time this year. Over the past five years the 453-bed hospital has concentrated on creating a comprehensive cardiovascular program. It's had a cardiac center of excellence, the Stead Heart Center, since 1986, and added a focus on vascular care and stroke care in 2006 (at which time the center was renamed the Stead Heart & Vascular Center). The change made it easier to coordinate care, says medical director Rama Thumati. “Before, the vascular surgeons were scattered among different groups, but now they're part of the team.”

Teamwork has been the key to several successful cardiovascular quality initiatives. A project among hospital cardiac staff and local paramedics has slashed door-to-balloon time (a crucial metric for survival of angioplasty candidates) from 180 minutes to 47. Pomona also has won kudos for a major push to cut readmission rates for congestive heart failure patients, who are taught to follow diet, exercise and medication regimens very strictly, and have a team of nurses providing ongoing oversight to make sure they keep toeing the line.

Henry Ting

St. Marys Hospital in Rochester, Minn., part of the Mayo Clinic, is back on the list after appearing there the first and third years of the study and then dropping off. The 797-bed hospital has made concerted efforts over the past five years to identify and concentrate on the elements of care that are most likely to improve its outcomes, says Mayo cardiologist Henry Ting.

“For every quality-improvement intervention, we measure and evaluate and study until we know how much of a difference we made and why,” he says. “A lot of organizations chase after process improvements and how to perfect them, but we want to make sure each intervention really makes a difference.”

St. Marys' door-to-balloon time is 30 minutes, down from 90 minutes in 2004. Ting knows exactly how much that improvement has affected patient outcomes: Research has shown that every additional 30 minutes correlates to an 8% increase in mortality.

One change contributing to the decrease is an easier to understand consent form at the catheterization lab, written at the sixth-grade level and individualized so patients with conditions like diabetes or renal failure can understand the risks and benefits for their particular conditions.

To cut readmission and mortality rates, Mayo has an initiative to encourage cardiac patients to stay on their medications.

“When patients are prescribed medications, half of them stop taking them within a year, so we're developing decision aids to help them understand their risk of dying or having another heart attack,” Ting says.

The materials feature pictograms with red and green faces representing percentages of patients who live and die under certain conditions. The “medication adherence” pictogram features a significant jump in the number of green faces.

Like all of Mayo's quality-improvement efforts, this one will be carefully tracked.

“A lot of the work we do in quality improvement is not rigorous enough that we know it actually works,” Ting says. “That's the science we need.”

---

Elizabeth Gardner, a former Modern Healthcare reporter, is a freelance writer based in Riverside, Ill. Reach her at gardnerem@sbcglobal.net.