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Reducing Costs and Length of Stay and Improving Efficiency and Quality of Care in Cardiac Surgery
Reducing Costs and Length of Stay and Improving Efficiency and Quality of Care in Cardiac Surgery Lawrence H. Cohn, MD, Donna Rosborough, RN, and John Fernandez, MPA Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
Background. The present era of health care places major emphasis on significantly reducing cost and resource utilization while maintaining quality of care and patient satisfaction. Clinicians are being challenged to achieve this within the framework of a patient subset that is increasing in severity of disease and risk-adjusted mortality. The Brigham and Women’s Cardiac Surgical Services Management Group was formed in 1987 to help accomplish these goals. Methods. The principles we have followed involve protocols and people. The multidisciplinary group includes the chiefs of cardiac surgery and anesthesia, chief residents, physician assistants, perfusionists, intensive care unit nursing personnel, and case managers. Weekly meetings address every aspect of problems arising in the cardiac surgical service; separate weekly morbidity and mortality conferences are held. The Care Coordination
Team establishes and monitors clinical pathways and recommends ways of improving all aspects of the service through a process of daily review on an individual patient basis. Results. The volume of cardiac surgery at Brigham and Women’s Hospital has increased steadily. The length of stay overall has decreased about 15%, and similarly, cost and total charges have also decreased. In addition, patient satisfaction has increased to a level of about 95%. Conclusions. The goals of cost-containment with improved patient care and outcome are possible through the collaborative efforts of representatives of all the personnel involved in cardiac care, as well as leadership by the surgical faculty.
C
Cardiac Surgical Service Management Group
urrent goals for cardiac surgical services, whether academic or private practice, are to increase volume of operations, to decrease overall patient length of stay, and to reduce costs, while simultaneously maintaining or even improving patient satisfaction and quality of care. This must be done within the framework of a patient subset generally acknowledged to be characterized by increasing severity and acuity of illness, risk-adjusted morbidity related to age, and complications of interventional cardiology. This presentation discusses some personal approaches to protocols and administrative techniques designed to help accomplish these goals. At Brigham and Women’s Hospital, both our total cardiac surgery and our coronary bypass case loads have gradually increased over the last few years. In 1996, about 1,800 patients underwent cardiac operations at our institution; of these, about 1,550 underwent open heart operations. The open heart operations included about 500 cardiac valve operations, about 850 coronary artery bypass graft (CABG) operations, and about 200 other procedures that included repair of thoracic aorta aneurysms and corrections of adult congenital defects. Thus, our patient population is heterogeneous from a medical as well as logistical standpoint, making for extremely complex care considerations. Presented at Risk Management in CABG: Analysis of Critical Issues, San Diego, CA, Feb 1, 1997. Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1997;64:S58 – 60) © 1997 by The Society of Thoracic Surgeons
When one of us (Dr Cohn) became chief of the cardiac surgery service over 10 years ago, he determined that we needed to take a comprehensive look at how to approach the management of an anticipated increasing volume of very complex cases. It was clear that we needed to devise an approach that could identify and react to problems in a very complex service with both a large in-hospital and out-of-hospital resource utilization. We adopted an approach patterned on that pioneered by many large Japanese corporations, in which all relevant personnel regularly meet together and work out problems as a team. Following this pattern, we formed the Brigham and Women’s Hospital Cardiac Surgical Service Management Group, consisting of the key persons representing all elements of the service: Chief, cardiac surgery Director, cardiac surgery intensive care unit (cardiac surgeon) Chief resident, cardiac surgery Chief, cardiac anesthesia Director, clinical cardiology Head, physician’s assistants Chief, cardiac perfusion Nurse in charge: Operating room Intensive care unit Intermediate care Care coordinator 0003-4975/97/$17.00 PII S0003-4975(97)01158-2
Ann Thorac Surg 1997;64:S58 – 60
Business manager Hospital administration Meeting at 6:30 am every Wednesday without fail, this group discusses the problems of the cardiac surgical service in every conceivable dimension. Matters discussed may range from something as banal as “Why do we have so much stuff in the corridors?” to “We need an entire operating room surgical suite completely remodeled, at a cost of $5 million, and why wasn’t it done last week?” This approach enables us to quickly get on top of every problem that arises in the service—something we are obliged to do to ensure efficient resource utilization and to provide the best possible working conditions for our staff and the best possible care for our patients. Other hospitals have since adopted a similar approach and most have found it extremely valuable. Among other important contributions, this group was instrumental in defining the actual cost to our hospital of a CABG operation. An outside consultant group we contracted with worked closely with us, both collectively and individually, to arrive at this cost. Armed with this information, which few other hospitals have even 4 or 5 years later, we were able to effectively compete with other hospitals and health-care systems for third-party payer contracts.
Care Coordination Team We have established a Care Coordination Team for both cardiac surgery and cardiology as a service line in our hospital. It consists of a team manager, care coordinator (social worker), utilization review specialists for cardiology and cardiac surgery, and a resource specialist to assist in discharge planning. This team makes site visits to frequently used extended-care facilities; conducts preoperative patient education; educates physicians, nurses, patients, and families about discharge planning; develops projects to improve the standard of care of cardiac patients; develops clinical pathways and monitors variance data; provides clinical reviews to third-party payers, and serves as consultant to health maintenance organization nurse liaisons on complex cases. The Care Coordination Team’s services to patients include coordinating patient care through a process of daily review of patients, identifying patients for discharge planning, planning discharge to extended-care facilities, and coordinating complicated home-care discharge plans. The team also monitors delays in service and discharge planning, provides psychosocial and financial assistance to patients and their families, and provides medical reviews for insurance companies. Attention to posthospital care has assumed increased importance in the current health-care environment, particularly in the area of cardiac surgery. The impetus to reduce length of hospital stay is associated with a high readmission rate and a high rate of posthospital morbidity, with many localized aggravating problems causing patients to seek help in emergency rooms or clinics. Rates of readmission or visits to emergency rooms after dis-
RISK MANAGEMENT COHN ET AL COST REDUCTION IN CARDIAC SURGERY
S59
charge have been reported to be in the range of 25% to 30%. The cost-effectiveness of a hospital’s care increasingly may be judged not solely on the basis of length of stay but also by the hospital’s readmission rate and postdischarge morbidity rate related to such things as leg and sternal wounds. The Care Coordination Team plays a critical role in patient aftercare by virtue of its functions in preoperative patient education, discharge planning, and postdischarge follow-up. If informed from the outset to expect discharge on the fourth or fifth day after the operation, the patient will not be disappointed when not discharged on the third postoperative day and will be well prepared for discharge on the fourth or fifth day. If patients discuss potential extended-care facilities with a care coordinator preoperatively, a smoother discharge plan will result. The team’s site visits to extended-care facilities may detect problems even at facilities viewed as providers of good care; the direct or indirect pressure then exerted on these facilities commonly motivates them to make the necessary improvements.
Clinical Pathway Clinical pathway programs are important projects in our hospital. For cardiac surgery, the goal is a 5-day length of stay for all uncomplicated cardiac surgical patients, and not just patients undergoing CABG. In 1996, 50% of the 576 patients who were on this pathway completed it; the mean length of stay for all 576 patients was 7.8 days.
Follow-up Procedure Systematic follow-up can contribute significantly to reducing rates of readmission or emergency room visits after discharge. One of our office nurses calls every patient 48 hours after discharge to ascertain how the patient is doing. Often, some problem is detected, even when the patient is in a rehabilitation center. The problem may be as severe as, for example, a sternal wound infection, in which case the patient is brought back to the hospital immediately. There is a drop-in clinic in our office; when a patient calls about any wound problem, he or she is told to come in to have it looked at. A Visiting Nurse Association has an important role in our patient follow-up; all patients are set up with a visiting nurse upon discharge as an additional “safety net.” All patients have an obligatory check-up by their cardiac surgeon at 4 weeks postoperatively. Our postdischarge complication surveillance program permits us to document our 30-day complication rate; this enables us to identify a problem and act on it. For example, our data from August 1996 showed an unusually high rate of postoperative sternal and saphenousvein wound infections, albeit mostly very superficial ones. Alerted by these data, we were able to determine that some residents or physician assistants were not using preferred techniques, particularly in the saphenous-vein harvest wound site. At our morbidity and mortality conference, which is attended by nurses and physician assistants, we began stressing the importance
S60
RISK MANAGEMENT COHN ET AL COST REDUCTION IN CARDIAC SURGERY
Ann Thorac Surg 1997;64:S58 – 60
Table 1. Brigham and Women’s Hospital Postdischarge Complication Surveillance: Case Example
Date
Sternal Wounds, Major and Minor (%)
Saphenous-Leg Harvest Site Wounds, Major and Minor (%)
10 8.5 3.2
18 10 8
Aug 1996 Sept 1996 Oct 1996
Table 3. Brigham and Women’s Hospital Cardiac Surgical Service: Coronary Artery Bypass Grafting (Diagnosis-Related Group 107) Variable
1994
1995
1996
Volume LOS (days) Change (%)
333 8.4 ...
337 7.3 28
427 6.8 22
LOS 5 length of stay.
of using the appropriate techniques. Within 2 months, the infection rate dropped dramatically (Table 1).
Staff Retreats We periodically hold a cardiac surgical retreat, and all senior surgical staff as well as all members of the Cardiac Surgical Service Management Group participate. The retreats are scheduled on a Saturday as an in-house event, because our service continues to function at the same time. We try to review the entire process of patient admission, workup, operation, postoperative stay, discharge planning, and discharge. An important objective at these retreats is to make all our practices as consistent and uniform as possible. For example, when reviewing our cardioplegia routine we found that five surgeons were using blood cardioplegia and one was using crystalloid cardioplegia—a difference in practice that we had been unaware of. To standardize, all surgeons now use blood cardioplegia, providing the service with the benefit of simplification and cost reduction.
Effects on Length of Stay The effects of the protocols and practices we have adopted in the pursuit of greater efficiency can be seen in some data on volume and length of stay over the last 2 years (Tables 2, 3). For both catheterization and CABG (diagnosis-related group 106) and CABG only (diagnosis-related group 107), volume increased and length of stay decreased. Charges remained about the same. Of importance is that intensive care unit stays during 1995 and 1996 fell below the previous year’s utilization when we employed these strategies.
Integration of New Technology The integration of new technology may have a very positive impact on practice efficiency. Minimally invasive valve surgery can serve as a paradigm for what can be Table 2. Brigham and Women’s Hospital Cardiac Surgical Service: Catheterization and Coronary Artery Bypass Grafting (Diagnosis-Related Group 106) Variable
1994
1995
1996
Volume LOS (days) Change (%)
300 8.8 ...
353 8.4 15
449 7.1 28
LOS 5 length of stay.
accomplished with the introduction of good new technology. Since July 1996, we have used minimally invasive valve surgery in more than 120 patients having valve replacement or repair. Patient satisfaction increased because of decreased pain, increased mobility, and better cosmesis. Length of stay was significantly decreased; some patients did not require any days in the intensive care unit. Postoperative costs decreased in most patients older than 70 years, who most often require posthospital rehabilitation after sternotomy. When a minimal incision was used, less than 10% of patients undergoing minimally invasive operations required a posthospital rehabilitation facility. These benefits were accrued with the application of the identical quality of care with an overall mortality of less than 2% and less morbidity.
Patient Satisfaction Patient satisfaction constitutes an important bottom line in the evaluation of a service’s practices and procedures. Although we have decreased patient length of stay, patient satisfaction with our service remains high (Table 4). I believe that the major reason for this high level of patient satisfaction is that we have demonstrated through our various “safety nets” that we care about our patients postoperatively and are interested in taking care of them even after their discharge from the hospital.
Summary Through the collaborative efforts of every element of cardiac surgery support, significant reductions in cost and resource utilization can be accomplished while maintaining quality of care and patient satisfaction. Leadership by the surgical faculty, not hospital administration, is the most important element to organize administration and quality control programs in cardiac surgery. Table 4. Brigham and Women’s Hospital Cardiac Surgical Service: Patient Satisfactiona Variable Nursing care Physician care Would recommend BWH
Excellent (%)
Good (%)
Fair (%)
95 95 97 (Y)
3 4 3 (N)
2 1
a
Period covered: October 1, 1995, to June 30, 1996; number of patients surveyed: 464. BWH 5 Brigham and Women’s Hospital;
N 5 no;
Y 5 yes.
Background. The present era of health care places major emphasis on significantly reducing cost and resource utilization while maintaining quality of care and patient satisfaction. Clinicians are being challenged to achieve this within the framework of a patient subset that is increasing in severity of disease and risk-adjusted mortality. The Brigham and Women’s Cardiac Surgical Services Management Group was formed in 1987 to help accomplish these goals. Methods. The principles we have followed involve protocols and people. The multidisciplinary group includes the chiefs of cardiac surgery and anesthesia, chief residents, physician assistants, perfusionists, intensive care unit nursing personnel, and case managers. Weekly meetings address every aspect of problems arising in the cardiac surgical service; separate weekly morbidity and mortality conferences are held. The Care Coordination
Team establishes and monitors clinical pathways and recommends ways of improving all aspects of the service through a process of daily review on an individual patient basis. Results. The volume of cardiac surgery at Brigham and Women’s Hospital has increased steadily. The length of stay overall has decreased about 15%, and similarly, cost and total charges have also decreased. In addition, patient satisfaction has increased to a level of about 95%. Conclusions. The goals of cost-containment with improved patient care and outcome are possible through the collaborative efforts of representatives of all the personnel involved in cardiac care, as well as leadership by the surgical faculty.
C
Cardiac Surgical Service Management Group
urrent goals for cardiac surgical services, whether academic or private practice, are to increase volume of operations, to decrease overall patient length of stay, and to reduce costs, while simultaneously maintaining or even improving patient satisfaction and quality of care. This must be done within the framework of a patient subset generally acknowledged to be characterized by increasing severity and acuity of illness, risk-adjusted morbidity related to age, and complications of interventional cardiology. This presentation discusses some personal approaches to protocols and administrative techniques designed to help accomplish these goals. At Brigham and Women’s Hospital, both our total cardiac surgery and our coronary bypass case loads have gradually increased over the last few years. In 1996, about 1,800 patients underwent cardiac operations at our institution; of these, about 1,550 underwent open heart operations. The open heart operations included about 500 cardiac valve operations, about 850 coronary artery bypass graft (CABG) operations, and about 200 other procedures that included repair of thoracic aorta aneurysms and corrections of adult congenital defects. Thus, our patient population is heterogeneous from a medical as well as logistical standpoint, making for extremely complex care considerations. Presented at Risk Management in CABG: Analysis of Critical Issues, San Diego, CA, Feb 1, 1997. Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1997;64:S58 – 60) © 1997 by The Society of Thoracic Surgeons
When one of us (Dr Cohn) became chief of the cardiac surgery service over 10 years ago, he determined that we needed to take a comprehensive look at how to approach the management of an anticipated increasing volume of very complex cases. It was clear that we needed to devise an approach that could identify and react to problems in a very complex service with both a large in-hospital and out-of-hospital resource utilization. We adopted an approach patterned on that pioneered by many large Japanese corporations, in which all relevant personnel regularly meet together and work out problems as a team. Following this pattern, we formed the Brigham and Women’s Hospital Cardiac Surgical Service Management Group, consisting of the key persons representing all elements of the service: Chief, cardiac surgery Director, cardiac surgery intensive care unit (cardiac surgeon) Chief resident, cardiac surgery Chief, cardiac anesthesia Director, clinical cardiology Head, physician’s assistants Chief, cardiac perfusion Nurse in charge: Operating room Intensive care unit Intermediate care Care coordinator 0003-4975/97/$17.00 PII S0003-4975(97)01158-2
Ann Thorac Surg 1997;64:S58 – 60
Business manager Hospital administration Meeting at 6:30 am every Wednesday without fail, this group discusses the problems of the cardiac surgical service in every conceivable dimension. Matters discussed may range from something as banal as “Why do we have so much stuff in the corridors?” to “We need an entire operating room surgical suite completely remodeled, at a cost of $5 million, and why wasn’t it done last week?” This approach enables us to quickly get on top of every problem that arises in the service—something we are obliged to do to ensure efficient resource utilization and to provide the best possible working conditions for our staff and the best possible care for our patients. Other hospitals have since adopted a similar approach and most have found it extremely valuable. Among other important contributions, this group was instrumental in defining the actual cost to our hospital of a CABG operation. An outside consultant group we contracted with worked closely with us, both collectively and individually, to arrive at this cost. Armed with this information, which few other hospitals have even 4 or 5 years later, we were able to effectively compete with other hospitals and health-care systems for third-party payer contracts.
Care Coordination Team We have established a Care Coordination Team for both cardiac surgery and cardiology as a service line in our hospital. It consists of a team manager, care coordinator (social worker), utilization review specialists for cardiology and cardiac surgery, and a resource specialist to assist in discharge planning. This team makes site visits to frequently used extended-care facilities; conducts preoperative patient education; educates physicians, nurses, patients, and families about discharge planning; develops projects to improve the standard of care of cardiac patients; develops clinical pathways and monitors variance data; provides clinical reviews to third-party payers, and serves as consultant to health maintenance organization nurse liaisons on complex cases. The Care Coordination Team’s services to patients include coordinating patient care through a process of daily review of patients, identifying patients for discharge planning, planning discharge to extended-care facilities, and coordinating complicated home-care discharge plans. The team also monitors delays in service and discharge planning, provides psychosocial and financial assistance to patients and their families, and provides medical reviews for insurance companies. Attention to posthospital care has assumed increased importance in the current health-care environment, particularly in the area of cardiac surgery. The impetus to reduce length of hospital stay is associated with a high readmission rate and a high rate of posthospital morbidity, with many localized aggravating problems causing patients to seek help in emergency rooms or clinics. Rates of readmission or visits to emergency rooms after dis-
RISK MANAGEMENT COHN ET AL COST REDUCTION IN CARDIAC SURGERY
S59
charge have been reported to be in the range of 25% to 30%. The cost-effectiveness of a hospital’s care increasingly may be judged not solely on the basis of length of stay but also by the hospital’s readmission rate and postdischarge morbidity rate related to such things as leg and sternal wounds. The Care Coordination Team plays a critical role in patient aftercare by virtue of its functions in preoperative patient education, discharge planning, and postdischarge follow-up. If informed from the outset to expect discharge on the fourth or fifth day after the operation, the patient will not be disappointed when not discharged on the third postoperative day and will be well prepared for discharge on the fourth or fifth day. If patients discuss potential extended-care facilities with a care coordinator preoperatively, a smoother discharge plan will result. The team’s site visits to extended-care facilities may detect problems even at facilities viewed as providers of good care; the direct or indirect pressure then exerted on these facilities commonly motivates them to make the necessary improvements.
Clinical Pathway Clinical pathway programs are important projects in our hospital. For cardiac surgery, the goal is a 5-day length of stay for all uncomplicated cardiac surgical patients, and not just patients undergoing CABG. In 1996, 50% of the 576 patients who were on this pathway completed it; the mean length of stay for all 576 patients was 7.8 days.
Follow-up Procedure Systematic follow-up can contribute significantly to reducing rates of readmission or emergency room visits after discharge. One of our office nurses calls every patient 48 hours after discharge to ascertain how the patient is doing. Often, some problem is detected, even when the patient is in a rehabilitation center. The problem may be as severe as, for example, a sternal wound infection, in which case the patient is brought back to the hospital immediately. There is a drop-in clinic in our office; when a patient calls about any wound problem, he or she is told to come in to have it looked at. A Visiting Nurse Association has an important role in our patient follow-up; all patients are set up with a visiting nurse upon discharge as an additional “safety net.” All patients have an obligatory check-up by their cardiac surgeon at 4 weeks postoperatively. Our postdischarge complication surveillance program permits us to document our 30-day complication rate; this enables us to identify a problem and act on it. For example, our data from August 1996 showed an unusually high rate of postoperative sternal and saphenousvein wound infections, albeit mostly very superficial ones. Alerted by these data, we were able to determine that some residents or physician assistants were not using preferred techniques, particularly in the saphenous-vein harvest wound site. At our morbidity and mortality conference, which is attended by nurses and physician assistants, we began stressing the importance
S60
RISK MANAGEMENT COHN ET AL COST REDUCTION IN CARDIAC SURGERY
Ann Thorac Surg 1997;64:S58 – 60
Table 1. Brigham and Women’s Hospital Postdischarge Complication Surveillance: Case Example
Date
Sternal Wounds, Major and Minor (%)
Saphenous-Leg Harvest Site Wounds, Major and Minor (%)
10 8.5 3.2
18 10 8
Aug 1996 Sept 1996 Oct 1996
Table 3. Brigham and Women’s Hospital Cardiac Surgical Service: Coronary Artery Bypass Grafting (Diagnosis-Related Group 107) Variable
1994
1995
1996
Volume LOS (days) Change (%)
333 8.4 ...
337 7.3 28
427 6.8 22
LOS 5 length of stay.
of using the appropriate techniques. Within 2 months, the infection rate dropped dramatically (Table 1).
Staff Retreats We periodically hold a cardiac surgical retreat, and all senior surgical staff as well as all members of the Cardiac Surgical Service Management Group participate. The retreats are scheduled on a Saturday as an in-house event, because our service continues to function at the same time. We try to review the entire process of patient admission, workup, operation, postoperative stay, discharge planning, and discharge. An important objective at these retreats is to make all our practices as consistent and uniform as possible. For example, when reviewing our cardioplegia routine we found that five surgeons were using blood cardioplegia and one was using crystalloid cardioplegia—a difference in practice that we had been unaware of. To standardize, all surgeons now use blood cardioplegia, providing the service with the benefit of simplification and cost reduction.
Effects on Length of Stay The effects of the protocols and practices we have adopted in the pursuit of greater efficiency can be seen in some data on volume and length of stay over the last 2 years (Tables 2, 3). For both catheterization and CABG (diagnosis-related group 106) and CABG only (diagnosis-related group 107), volume increased and length of stay decreased. Charges remained about the same. Of importance is that intensive care unit stays during 1995 and 1996 fell below the previous year’s utilization when we employed these strategies.
Integration of New Technology The integration of new technology may have a very positive impact on practice efficiency. Minimally invasive valve surgery can serve as a paradigm for what can be Table 2. Brigham and Women’s Hospital Cardiac Surgical Service: Catheterization and Coronary Artery Bypass Grafting (Diagnosis-Related Group 106) Variable
1994
1995
1996
Volume LOS (days) Change (%)
300 8.8 ...
353 8.4 15
449 7.1 28
LOS 5 length of stay.
accomplished with the introduction of good new technology. Since July 1996, we have used minimally invasive valve surgery in more than 120 patients having valve replacement or repair. Patient satisfaction increased because of decreased pain, increased mobility, and better cosmesis. Length of stay was significantly decreased; some patients did not require any days in the intensive care unit. Postoperative costs decreased in most patients older than 70 years, who most often require posthospital rehabilitation after sternotomy. When a minimal incision was used, less than 10% of patients undergoing minimally invasive operations required a posthospital rehabilitation facility. These benefits were accrued with the application of the identical quality of care with an overall mortality of less than 2% and less morbidity.
Patient Satisfaction Patient satisfaction constitutes an important bottom line in the evaluation of a service’s practices and procedures. Although we have decreased patient length of stay, patient satisfaction with our service remains high (Table 4). I believe that the major reason for this high level of patient satisfaction is that we have demonstrated through our various “safety nets” that we care about our patients postoperatively and are interested in taking care of them even after their discharge from the hospital.
Summary Through the collaborative efforts of every element of cardiac surgery support, significant reductions in cost and resource utilization can be accomplished while maintaining quality of care and patient satisfaction. Leadership by the surgical faculty, not hospital administration, is the most important element to organize administration and quality control programs in cardiac surgery. Table 4. Brigham and Women’s Hospital Cardiac Surgical Service: Patient Satisfactiona Variable Nursing care Physician care Would recommend BWH
Excellent (%)
Good (%)
Fair (%)
95 95 97 (Y)
3 4 3 (N)
2 1
a
Period covered: October 1, 1995, to June 30, 1996; number of patients surveyed: 464. BWH 5 Brigham and Women’s Hospital;
N 5 no;
Y 5 yes.