Three years ago, the cardiovascular program at the University of Massachusetts Memorial Medical Center, Worcester, was abruptly shut down because its mortality rate was twice what the state thought it ought to be. Though the rate was close to the national average, plenty of Massachusetts hospitals were performing above that levelenough to make UMass Memorial look like an outlier.
The shutdown caused the 723-bed hospital to lose $26 million and its fellowship program in cardiothoracic surgery. It could have been a disaster, but instead turned out to provide needed breathing room to take stock of the program and figure out how to fix it, says Robert Phillips, a physician and director of the heart and vascular center of excellence, who arrived a month before the shutdown. Our short-term response was to create an environment of humility and media transparency, he says. That humility was what helped us become successful quickly.
The changes were dramatic. Cardiac surgeons and cardiologists began working more closely together, with formal review of high-risk cases. The cardiac surgery group developed a uniform set of practice protocols. All cardiology and cardiac surgery beds were consolidated on one floor, which included an 18-bed intensive-care unit.
The nursing staff was recruited specifically for the new unit and was cross-trained in cardiology and cardiac surgery. Phillips says at least one life was probably saved because a nurse-educator standing outside the patients room started CPR within 15 seconds of his cardiac arrest. I dont know if that would have happened four years ago, he says.
These days, the UMass Memorial cardiovascular program is a center of excellence in more than just name. The procedures and practices put in place during that time of trauma have led to a dramatic turnaround, and the hospital appears on this year's list of the 100 top cardiovascular programs in the U.S., compiled by business information firm Thomson Reuters.
Thomson Reuters examined the performance of nearly 1,000 U.S. hospitals by analyzing their outcomes for measures related to coronary artery bypass grafts, or CABGs, and percutaneous coronary interventions, or PCIs, such as angioplasties. The analysis used data from the CMS, including Medicare cost reports, Medicare Provider Analysis and Review, or MedPAR, data and information from the Hospital Compare quality-reporting Web site. It identified 100 hospitals that did significantly better than their peers on risk-adjusted measures of mortality and complications. They were divided among teaching hospitals with cardiac residency programs, teaching hospitals without cardiac residency programs and general hospitals.
Average survival rates and complication avoidance rates for cardiac patients have been improving in general, and the performance differential is slightless than 1 percentage pointbetween the winners and other hospitals. However, it can add up: if all hospitals performed at the level of the benchmark hospitals, it would save almost 6,000 lives per year and prevent nonfatal complications in an additional 720 patients, according to Thomson Reuters. Benchmark hospitals saved an average of more than $1,500 per case, Thomson Reuters reported.
Incremental improvements were the key to bringing up the performance of the cardiovascular program at 551-bed Erlanger Medical Center in Chattanooga, Tenn., which appears on the list for the first time this year. For some time now, weve had a very strong commitment to continuous improvement and the use of metrics, working to best practices and benchmarking ourselves, says James Brexler, president and chief executive officer of Erlanger Health System. The hospital publishes all of its quality data on its Web site, and the transparency helps keep the Erlanger team focused, he says.
Erlanger develops its best practices from multiple sources, including the Institute for Healthcare Improvement, the Cardiovascular Roundtable and multi-industry quality-improvement methodologies such as Six Sigma, says R. Cyrus Huffman, the hospitals chief medical officer. We take from everyone, but we have to get it to work here, he says. We have multiple cardiology groups, and building consensus is not an easy exercise.
This year Thomson Reuters did an additional study in conjunction with ECG Management Consultants, Arlington, Va., to measure how the benchmark hospitals differed from their peers in the amount of investment in their cardiovascular programs and how they measured their programs performance. The study found that the hospitals on the 100 Top cardiovascular list spent an average of $25 million over the three-year period on capital expenditures for their cardiovascular programs over the past three years, compared with $14 million in the peer hospitals. And nearly all98.5%considered financial performance to be a key metric in judging the success of the cardiovascular program, compared with 88.4% for the peer hospitals.
The benchmark hospitals are more likely to use a service-line model to track performance in their cardiovascular programs, says consultant Sue Anderson of ECG. Because cardiac services are a high-volume, high-cost area for most hospitals, theyre often the first to be organized and analyzed separately from other hospital services. Being able to monitor financial performance can be difficult for political reasons, she says. Transitioning to a service-line structure is a matter of getting buy-in from the physicians and making them partners.
The whole industry is moving toward service lines to increase accountability for clinical and financial performance, says Jean Chenoweth, senior vice president of performance improvement and the 100 Top Hospitals programs at Thomson Reuters. These hospitals are leading because theyre incorporating some of the financial metrics into their internal evaluation of their success.
For example, 111-bed Banner Heart Hospital in Mesa, Ariz., where cardiac care is the only service line, enlisted its medical staff to drive down costs for electrophysiology devices by showing them pricing data and explaining the tactics that vendors use to manipulate physicians choices. We showed them that we can get better pricing if we all use one or two devices and present a united front, says CEO John Harrington. The hospital has been on the 100 top cardiovascular list for three consecutive years.
Banner has invested heavily in technology, with a da Vinci robotic surgery system and a full-time surgeon who uses it to do bypass grafts, mitral valve replacements and other common cardiothoracic procedures.
The hospital has also spread its cardiovascular expertise into the community, educating emergency medical personnel in three area cities to read electrocardiograms in the field and bring patients directly to the cardiac catheterization laboratory if necessary. Emergency medical technicians call ahead and the physician is often waiting when the patient arrives. The strategy has shortened door-to-catheterization- laboratory time by half an hour.
Elizabeth Gardner is a former Modern Healthcare reporter and a frequent contributor to the magazine. Reach her at [email protected]