For six weeks in late 2005, UMass Memorial Medical Center voluntarily stopped performing elective cardiac surgery after Massachusetts Department of Public Health (DPH) data indicated that the medical center's CABG mortality was above the state average. Things have since turned around and UMass is now a recognized national leader in quality and cardiovascular outcomes, according to a commentary from Robert Phillips, MD, senior vice president at UMass.
Being humbled by the closure of the cardiothoracic surgery program provided the catalyst for this major shift in cardiovascular performance. Everyone was embarrassed and wanted to make the organizational changes that would not only prevent a slip in quality, but also create the platform for success.
“What a difference four years makes,” said Stanley Tam, chief of cardiac surgery. “Mortality rates for CABG are one percent, while the average in Massachusetts has been about two percent.”
Two major organization shifts propelled the success. Primarily through the leadership of Walter Ettinger, MD, UMass Memorial established the Clinical Performance Council in 2006. The council was created to focus exclusively on quality and patient outcomes. The second important piece to the reorganization was the development of a truly 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 (COE).
The focus on quality is now ingrained at the highest levels of the organization. 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 Memorial identify other opportunities and areas for improvement. Also, a focus on door-to-balloon time for MI helped us to 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,” explained John Keaney Jr., MD, chief of cardiovascular medicine. Keaney noted 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.
Since 2005, the COE has been the driving force for creating integrated care in the service line. In four years, the center has unified all cardiovascular services into the UMass Memorial Heart and Vascular Hospital, with virtually all units (ICU, step-down and acute care) diagnostic imaging and faculty offices located on the third floor of the hospital and adjoining medical school buildings.
To facilitate integration and coordinated care, nurses in the ICU have been cross-trained to care for both post-operative cardiac surgery patients and cardiac medical CCU patients, and rotate on a regular basis to maintain their skills. Step-down unit nurses have additional training in post-op vascular care.
Physicians have a weekly clinical meeting to review cases, which brings together cardiologists, surgeons, anesthesiologists, radiologists, nurses, mid-level providers and technicians. Physicians and administrators have monthly meetings to review the progress of the center’s strategic plan, operational issues and financial performance.
The COE has its own monthly surgery executive committee that advocates for the needs of its surgical program within the institution. “The strength of our integration is illustrated by the decision-making process to build a hybrid vascular operating room,” said Louis Messina, MD, chief of vascular and endovascular surgery. “Our regular COE surgery meetings