UMass Memorial: Heart and Vascular Center of Excellence
While technology is an important factor in healthcare excellence, other ingredients are equally important. They include a bold vision, capable leadership to attain that vision, teamwork and intelligent data mining.
UMass Memorial Medical Center in Worcester, Mass., is a superior example of blending leadership and technology. In 2005, the hospital voluntarily stopped performing elective cardiac surgery after data indicated its CABG mortality was above the state average. The experience was humbling for UMass, but the organization rose to the challenge and has since been recognized as a national leader in quality and cardiovascular outcomes.
“Being humbled by the closure of our cardiothoracic surgery program provided the catalyst for this major shift in cardiovascular performance,” says Robert Phillips, MD, senior vice president of UMass and director of its Heart and Vascular Center of Excellence.
Two major organizational shifts propelled the transition. Primarily through the leadership of Walter Ettinger, MD, president of UMass, the hospital established the Clinical Performance Council in 2006, in order to focus exclusively on quality and patient outcomes. The second important piece was the development of an integrated clinical, operational, financial and quality program for CT surgery, cardiology and vascular surgery under the organizational structure of the Heart and Vascular Center of Excellence.
The focus on quality is now ingrained at the highest levels of the organization, says Phillips. The clinical performance council is a bi-monthly meeting that includes all clinical chairs, key administrators and members of the board of trustees. This committee regularly reviews, gathers, analyzes and acts on quality assurance data. The performance council review system includes quality walk-a-rounds from senior leadership that focus on strict adherence to processes and procedures.
This focus on outcomes helped UMass identify other opportunities and areas for improvement. A focus on door-to-balloon (D2B) times for MI, for example, helped UMass garner the No. 2 spot nationally and the No. 1 spot in Massachusetts for heart attack survival from the Centers for Medicare & Medicaid Services.
“We began to drill down and analyze every aspect of the process,” says John Keaney Jr., MD, chief of cardiovascular medicine. Keaney notes that identifying the components of the process was a critical first step. Once these segments were identified, individual time goals were established to help clinical leaders improve overall D2B times.
“Our intent wasn’t to change clinical practice, but to change how we coordinate the process of care and its impact on patient outcomes,” Keaney said. “Each step in the process was examined for inefficiencies, duplication and standardization. We partnered with our colleagues in the emergency department and with local and regional EMS to create the most efficient system. The results are impressive: D2B times now average less than one hour, while the national standard is 90 minutes.”
Local ambulances now are equipped to send ECGs wirelessly to the emergency room and to the on-call physician’s phone, which helps to activate the cath lab in a timely manner. The hospital has adopted the use of cooling helmets, initially for use only in the cath lab, but now they are applied in the ER, says Craig S. Smith, MD, director of the coronary intensive care unit at the Heart and Vascular Center of Excellence. In the process, the UMass team has created a new metric: door to cooling-core-temperature time.
The Heart and Vascular Center of Excellence has its own monthly surgery executive committee that advocates for the needs of its surgical program. “The strength of our integration is illustrated by the decision-making process to build a hybrid vascular operating room,” says Louis Messina, MD, chief of vascular and endovascular surgery.
The performance also has had an impact on finances. “From 2006, the first year that the cardiac surgery program reopened, to 2008, profit in the Heart and Vascular Center of Excellence has increased by 260 percent,” says Jay Cyr, vice president of the Heart and Vascular Center of Excellence. “This has been accompanied by the addition of 80,000 square feet of cardiovascular ICU and step-down unit space, and a planned 2010 opening of nearly 40,000 square feet of new ambulatory and clinical research space.”
UMass utilizes a remote, or electronic, ICU (eICU) monitoring program for its critical care patients. The eICU (Visicu; Philips Healthcare) allows intensivists and critical-care nurses at the eICU command center to make virtual rounds of patients through an elaborate network of cameras, monitors and two-way communication links via T1 lines.
“We are able to have a board-certified full-time intensivist watch ICU patients all the time,” says Smith. “That’s clearly the best utilization of this software—for us and the nation as a whole—because most of the hospital beds in this country are located in rural areas where physician and intensivist staffing can be tight.”
All critical care data are tracked by the eICU system and analyzed to determine how the various facilities are adhering to evidence-based practice guidelines. These data are reviewed monthly, quarterly and yearly with all the ICU directors, who then take the data to their ICU teams. All outliers—whether positive or negative—receive special attention to determine what went right and how to reproduce those results or what went wrong and how to minimize the chances of it happening again, Smith says.
The effort to amass, sort and analyze these data generated by the eICU is Herculean, Smith says, and it takes a very strong infrastructure to process it in a meaningful way.
Metrics and benchmarks can be moving targets, especially as landmark trials reveal new evidence contrary to conventional practice. It was common, for example, to grade hospitals on the timeliness of administering beta blockers to heart attack patients. New evidence, however, suggests this practice may not be beneficial within the first 24 hours post-MI. “We have to make sense of the data and make the changes to the eICU data collection process when appropriate,” Smith says.
UMass uses a simulated training center, which has helped reduce infection. Physicians can practice inserting central lines for IV access and intubating, for example, on intelligent mannequins. They then become credentialed and perform these procedures under the watchful eye of the eICU. “As a result, our complications from line placements and central line infection rates have plummeted,” Smith says.
“We know that every central line infection costs the hospital $20,000 and adds two weeks of antibiotic treatment to the patient. With the simulated training, we have reduced our infection rate by one-third. Some critical care units have gone a year without a line infection,” Smith says, adding that as a resident, it was commonplace to have two to three line infections a month.
The Heart and Vascular Center of Excellence also utilizes “smart scales” for heart failure patients. Home-bound patients weigh themselves daily and the results are transmitted to the heart failure team via a wireless receiver. Nurses who spot unusual weight gain can instruct the patient regarding medication, thus avoiding a hospitalization. The next step, says Smith, is to have implantable cardioverter-defibrillators (ICDs) measure the fluid in the lungs via electrical impedance and wirelessly transmit that information to the hospital. “We want to keep people out of the hospital,” Smith says.
The Heart and Vascular Center of Excellence is at the forefront of aggressive efforts to improve patient care. “By integrating cardiologists, cardiac and vascular surgeons, sophisticated technology, and the latest advances in medicine, we are able to provide patients with a complete continuum of care,” says Phillips. “We are fortunate to have leaders at UMass Memorial Medical Center who embraced the vision and commitment to total care.”