Is Your Cardiovascular Program meeting Goals? by Marsha L. Knapik, RN, MSN, CCRN

In today’s highly competitive health care market with cardiovascular services comprising as much as 40% of acute care revenues, it makes sense to take a critical look at that service line to see where it stands and where it is going.

All acute care hospitals provide some level of cardiac services, ranging from non-invasive diagnostics to full invasive and surgical cardiac care. Yet very few program administrators take the time to thoroughly assess how their programs stack up.

Successful cardiovascular programs demand ongoing attention to the effectiveness of all the factors that influence results. These include organizational structure, data systems and information management, quality assessment and performance improvement, operational efficiencies, personnel utilization and management, finance (cost and revenue), and program marketing.

The CV services administrator must appreciate and understand where the business comes from and where it goes. Other issues are equally important. What does it cost to run the business and who can run it? What will it take to grow the business and in what direction should it grow?

The best way to address these questions is to periodically perform an internal program self-assessment.

Begin with a review of the organizational structure for all services related to the provision of cardiovascular care. In a service line model this is easy, as all cardiovascular service areas report either directly or indirectly to a CV administrator or director.

This allows for information regarding each individual service to be reviewed not only in the context of the individual service, but also within the scope of the overall cardiovascular program. Surprisingly, very few hospitals take a true service line approach, in which all information related to the service line flows to a central point for review and decisions.

Service silos can be barriers to success

If the present structure does not allow for service issues, volumes, costs and patient outcome data from individual departments to be reviewed by a CV Administrator in context with the other cardiac services provided, the hospital essentially is providing multiple cardiac services in isolation from every other cardiac service. These service silos make it difficult to distinguish what issues are having an impact on the institution’s services, where the real problems are coming from, what the program’s strengths are, and what interrelationships exist between services.

Many cardiovascular services overlap. Take, for example, a patient with an abnormal treadmill stress test who is referred for a cardiac catheterization. In turn, a patient with abnormal cardiac catheterization is referred for coronary artery bypass graft (CABG) surgery. Upon discharge, a patient who has had CABG surgery is referred to cardiac rehabilitation. Thus, it is critical to be able to monitor cardiac services as a whole as well as individually.

Data systems and information management

Take a close look at how your hospital currently collects data, manages data and reports results for CV services. Data management is critical to a successful CV services program so that overall volumes, costs, revenues and outcomes can be reviewed and acted upon.

Data collection and management can be performed in many ways, ranging from the use of manual data extraction and compilation processes to integrated automated data management systems that incorporate financial and clinical data. Although the use of a computerized data management system will be more efficient, it can also be expensive. The level of sophistication of the data management system is not as important as the types of data collected and reported and how they are used to review overall program operations and outcomes.

Software to collect American College of Cardiology (ACC) and Society of Thoracic Surgeon (STS) data is of great value in terms of the data elements collected and how that data can be used internally to review patient outcomes and individual physician practices.

Data from all areas of the cardiac service line should be reviewed in an integrated fashion. A committee should be established to review the service line data, make recommendations, and initiate actions for change. This committee is usually a part of the hospital’s quality improvement/process improvement program and should be multidisciplinary.

Quality assessment, performance improvement

Quality assessment (QA) and performance improvement (PI) in the cardiovascular program is closely related to and interdependent with data and information management. Appropriately evaluation of the CV program requires an administrator to know what indicators regarding volumes, finance, and patient care outcomes are being monitored once the data is collected. The administrator must then ask a series of follow-up questions:

• How is the information analyzed and, most importantly, how is the information used to promote change?

• Is there an established process in the CV program to give performance feedback to the staff and physicians?

•When problems are identified, what is the methodology for root-cause analysis?

• How is a plan for change implemented?

• Once change has been implemented, how is reevaluation completed?

In summary, it is imperative to identify key indicators, monitor them closely and act quickly on areas of concern.

An administrator can also skillfully apply trending techniques to the data when a negative pattern is identified, which can be very helpful in motivating staff and physicians to take proactive measures to solve problems. Physician “report cards” that identify individual physician practice patterns such as length of stay, cost per case and clinical outcomes are also useful. A medical advisory committee is a valuable way to identify and manage physician performance issues.

Although personnel performing each service may monitor indicators for QA/PI, the data from all service areas should be integrated to reflect overall program performance and identify opportunities for interdepartmental process improvement. Be sure to make use of national data benchmarks from organizations such as ACC, STS and NRMI (National Registry of Myocardial Infarctions) to compare your program data with outside performance references.

Don’t overlook the importance of assessing participant satisfaction (patient, physician and staff) in your CV program. Periodic surveys of these groups provide valuable information regarding the strengths and weaknesses of the CV program from each participant’s perspective. Patient concerns may focus on the ease of access, quality of care and personal service. The physician may be more concerned with how quickly and easily patients can be scheduled, accommodation of the physician’s schedule for CVOR or cardiac catheterization lab time and availability of the latest equipment and technology. The clinical staff may be concerned about salary and benefits, staff-to-patient ratios and work schedule flexibility.

Operational efficiencies

Programs must be reviewed periodically for core program factors. Consider your responses to the following basic considerations:

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BIO:

Marsha’s cardiovascular experience has included clinician, critical care educator, cardiac clinical nurse specialist and manager. Marsha received her R.N. Diploma from The Washington Hospital School of Nursing and her undergraduate degree from the Pennsylvania State University. She has a Masters Degree in Nursing with a Cardiovascular Clinical Specialty from the University of Pittsburgh.

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