This month, we have a great article from Anne Beekman, Senior Consultant with MedAxiom. Her overview of a recent survey conducted among cath labs across the country is very telling and should be viewed with an eye towards looking inward at your program and asking whether you are prepared for this new healthcare environment. Healthcare costs are continuing to rise, revenues are decreasing, and payers and patient demands are not diminishing. Cath lab programs are facing these challenges and more. This MedAxiom survey definitely has demonstrated some significant findings that I am sure they will be sharing in their totality in the near future.
— Gary Clifton, Vice President, Terumo Business Edge
The challenges to being a best-in-class interventional program are well known. These challenges are extensively documented and frequently discussed. Cath lab programs know they must move to a value-based model, develop an outpatient strategy, an actionable cost accounting system, and a solid dyad leadership. The issue is not identifying problems or stating the desired outcomes, but that the action steps to get a program to real change are missing. With so many priorities coming at physicians and leaders, what are the best-in-class programs doing to move the needle? Best-in-class programs do have similar areas of focus and attributes that align them with success. These data come from a cath lab best practice survey released by MedAxiom in 2017. The survey includes responses from over 80 physicians and program leaders, identifying program priorities and the ability to drive change in quality, finance, value, leadership, and operational performance. The focus will be on two steps:
1) What resources do you need to do the work to become a best-in-class program?
2) And if you have the resources, what are the steps to moving to best in class?
Creating an actionable map and finding dedicated resources to facilitate a program moving into best-in-class cath lab performance is the missing part of the equation. So, how do does a program move from identification of the needed work and the desired deliverables to an actionable plan? Unfortunately, the identification of the need and the desired deliverables is the easy part. It is the middle section, the day-to-day work, where the heavy lifting occurs. This is the part where many programs struggle to find the time and resources to support change. Are there attributes that identify program readiness for undertaking this work? The answer is yes. First, prior to even investing in a planned action, programs must take stock of their basic infrastructure. If a program is missing any of the following key roles or attributes, take a time out before embarking on change. Without the following foundational work and resources, your interventional program will struggle or fail to achieve a best-in-class program vision:
Three foundational requirements to begin moving your program to Best in Class:
Resources: Physician and Leadership. This does not mean having a champion. It is assumed a champion is already in place. The work requires dedicated time in physician and leadership schedules: a minimum of 8 hours a week for significant program initiatives such as a value-based agenda or moving a difficult quality metric such as mortality.
Data: Programs today are inundated with data, yet have very limited resources around data analytics. If a program cannot provide timely accurate data around a desired deliverable – for example, something as basic as cost per case — the program is not ready for action. In the MedAxiom cath lab survey, programs ranked the importance of cath lab financial performance on a 1-10 scale, with a 10 being most important. Fifty-four percent of survey responders assigned a 7 or above to the question. Yet today, only 18% report they frequently measure and report economic data in the cath lab. Having this financial data and the venue to review as a team sets up these programs to be best in class for financial performance. In contrast, 14% of reporting programs do not see or review cath lab financial data. These programs find themselves at a significant disadvantage in a value-based negotiation.
Incentives: Programmatic change can be established without placing incentives on the work. However, as more focus for physicians and leadership moves to pay for performance, it is natural for energy and time to be focused on work that is incentivized. Work that involves behavioral change or clinical learnings requires time and attention. This type of change will move slowly, if at all, unless the work is aligned with overall program incentives. A good example is radial access for ST-elevation myocardial infarction (STEMI). The data are compelling for STEMI care provided with a radial approach and the resulting reduction in complications. However, in the MedAxiom cath lab survey, programs report a relatively low use of radial for this patient population.
As Figure 3 demonstrates, 39% of programs have an opportunity to expand radial coverage to their STEMI patient population. Transitioning to a radial approach, especially in high acuity cases, can be a steep learning curve for physicians. With proper incentives, however, there is a greater likelihood of practice change. Best-in-class programs are leaders in this metric from a quality perspective.
After taking a review of your program infrastructure, complete the following checklist:
- Identified physician leader – actively working with the project (4 hours week);
- Identified administrative lead – actively working with the project (4 hours week);
- Accurate data to measure work;
- Access to real-time data;
- Ability to analyze data;
- Adjustment to data queries as needed;
- Incentives that drive the work.
Congratulations if you passed this checklist! It is easy to see why so many programs can identify where they want to go, but lack the horsepower to move work into real change. The resources needed for the work are already in high demand, and have job descriptions and requirements that do not include this dedication to program change. Basically, the people needed for the work have real jobs they need to do as part of the daily workload. The necessary program optimization work in many systems is intended for the process improvement teams or lean programs. Unfortunately, too often, these teams are assigned months out and tend to focus on very operational work such as supply chain management. The clinical and process improvement (PI) skill set needed for the necessary changes to move to best-in-class work, such as moving from volume to value, is often much harder to find. In addition, some programs are faced with reducing or eliminating PI teams, as programs face margin deficits and all efforts are made to protect direct care full-time employees (FTEs). The end result is program change and optimization work falls to experienced physician and administrative leaders.
What we know is that programs that can achieve best-in-class rankings have resources that run much deeper than just the clinical team. So how do they use these resources to help lead change in their programs?
These programs don’t just review registry and quality data, but have a venue and team to take action and make change.
Fourteen percent of programs in the survey “review and frequently revise care pathways” around the procedural patients. We tend to see best-in-class programs lead in several of the survey categories. An example is readiness for a bundle payment model. The survey data shows that 26% of responders have completed bundle payment discussions or are fully prepared. Surprisingly — or not — there is high crossover between programs that frequently review clinical practices and those that are ready for bundles and value-based care.
What the data suggests is that programs that are able to move to best-in-class practices have the infrastructure to make change and the physician leadership to support it. Persistent review and constant adjustment appears to be part of their culture, and these programs know the recipe for effective change. What we know is most cardiovascular programs are aware of where healthcare is headed and can accurately measure their position and deficiencies. What many programs lack are the resources to do this work. Relying on the traditional physician and leadership roles to move change forward at the rapid pace required today is not sustainable or productive. Meeting the criteria in the checklist above is not an overnight event. It requires in investment in time, talent, and finances. The reality is that programs that do not invest resources for program change and optimization will continue to struggle, while best-in-class programs will benefit.
If your hospital would like to participate in the cath lab survey, please follow the link below:
You will receive a personal report with benchmarking within 10 business days.