With $1B and a top rating, service line still strives for better

BEAVER CREEK, Colo.—Even the best can do better. Michael Mack, MD, medical director of cardiovascular surgery at Baylor Scott & White Health in Dallas, shared strategies used by his cardiovascular service line that helped place them among top performers as well as the challenges they still face.

Speaking June 18 at the MedAxiom Cardiovascular Service Line Symposium in Beaver Creek, Colo., Mack used the Society of Thoracic Surgeons’ (STS) three-star rating system as the launching point to discuss strategies for improving a cardiovascular surgery program. The star ratings are a composite, risk-adjusted score based on data submitted by 1,150 cardiac surgery programs in the U.S. for CABG, aortic valve replacement (AVR) and CABG and AVR.

Three stars go to best performers, two to average performers and one to worst. Consumer Reports publishes ratings based on STS data.

“This is a widely accepted barometer of quality,” Mack said.

Only 1.2 percent of programs earned three stars in Consumer Reports and the Heart Hospital Baylor Plano, where Mack is chairman of the research center, and Baylor University Medical Center, also part of Baylor Scott & White Health, both made the three-star grade. By volume, Heart Hospital Baylor Plano’s valve surgery program is the 10th largest in the U.S.

“You have to have good surgeons and you have to have good infrastructure,” he said. “By the time you get to a certain level, you have to get very much down in the weeds to move the needle further.”

Leaders initiated a number of strategies that focus on the heart center but are being expanded to other parts of its cardiovascular service line, which is a $1 billion business, according to Mack. Public reporting remains a top priority with an emphasis on transparency. They also schedule semi-annual best care meetings that provide unblinded, peer-review reporting.

“Every surgeon gets in the room and their outcomes are unblinded in front of every other surgeon,” Mack said. “We now do the same thing with interventional cardiology and we are starting it for electrophysiology and vascular surgery.”

The center also mandates a second opinion for patients who have a predicted risk of surgical mortality of greater than 5 percent, which Mack credits for improvements in patient selection. Surgeons may feel pressured by a referring cardiologist, a family member or even themselves to treat a high-risk patient surgically. “When you get into a service line team environment, it is easier to have these discussions,” he said.

The program borrowed several quality improvement models from other institutions, including phase of care mortality analysis (POCMA) from the Michigan Society of Thoracic and Cardiovascular Surgeons and a baseball card approach from the Cleveland Clinic.

Using POCMA, the center undertakes a root-cause analysis for every cardiac death. Cause of death is divided into pre-, intra- and post-operative phases in the intensive care unit, on the floor or after discharge to assess whether the death was avoidable. If avoidable, they then identify the initial problem.

As many as 70 percent of deaths may be avoidable and 35 percent due to pre-operative patient selection. “That patient should never have had surgery or had surgery at the wrong time.” He emphasized that, in some cases, the best care for a patient is counter to guideline recommendations, and a heart team approach with physicians conferring about a course of care can help identify those instances.

They started with a surgeon-only POCMA program, but to be most effective they have included cardiologists, anesthesiologists, intensivists and mid-level providers who can help change processes.

They apply a baseball card concept that lists risk-adjusted scores and benchmarks for surgeries and more complex procedures to the heart center and to individual surgeons. “Each surgeon gets a baseball card so they know their performance year by year.”

They also participate in the Texas Quality Initiative and have set up care pathways to facilitate good outcomes.

“We are strong believers in quality,” he said. “That is what matters. … If quality is not what matters at the end of the day then we are in a race to the bottom as we compete for price.”