Inova Health System

Cardiovascular Disease Task Force

Report of Task Force Findings and Recommendations

Working Draft 6-28-04

I. Introduction

The following is a summary of the findings, conclusions and recommendations of the Cardiovascular Disease Task Force. The Cardiovascular Disease Task Force was convened to review the concept of a long-term, exclusive agreement for cardiac surgery services between Cardiovascular and Thoracic Surgery Associates (CTSA) and Inova Health System.

II. Background

For some time, ongoing discussions had taken place between Inova Health System and Cardiovascular and Thoracic Surgery Associates (CTSA) about establishing an exclusive agreement for cardiac surgery. Pending execution of a definitive exclusive agreement, Inova and CTSA entered into a letter of agreement granting CTSA exclusivity for cardiac surgery services. Prior to finalizing the long-term exclusive agreement, Inova administrators spoke with cardiology leaders who expressed significant concerns about establishing such an agreement.

The cardiologists' concerns related to perceived inequities in relationships between cardiologists, cardiac surgeons and the Inova administration. It was their belief that an exclusive agreement did not fit with the private practice medical model of the Inova hospitals and that such an agreement could make cardiac surgeons less responsive to the needs of cardiologists. Concerns also were expressed about maintenance of quality and the adoption of new technology and techniques by the present cardiac surgery group. At a special meeting of the Cardiology Section in November 2003 members voted unanimously against the establishment of an exclusive agreement for cardiac surgery.

In response to the cardiologists' concerns about maintaining quality care and ensuring access to state-of-the-art cardiac surgery under a long-term exclusive agreement with CTSA, Tim Wright, MD, president of the medical staff, Inova Fairfax Hospital and Inova Fairfax Hospital for Children, convened the Cardiovascular Disease Task Force on December 19, 2003. The task force was asked to:

  • Facilitate direct communication between cardiac surgery, cardiology and other representatives of the medical staff and administration around this issue
  • Determine how to ensure and enhance the quality of cardiac surgery and cardiology at IFH and IFHC
  • Review best practices and models for cardiac surgery and cardiology
  • Determine the impact of potential multiple cardiac surgery groups on the quality and future of cardiac surgery at IFH and IFHC
  • Review issues, old and new, concerning cardiac surgery and cardiology

The task force, chaired by Richard Binder, MD, has meet every two weeks since January 13, 2004 to accomplish the assignment. The members of the task forces are as follows:

Ali Assefi, MD

Barry Dicicco, MD

Kristen Edminston, MD

Cleveland Francis, MD

Seymour Hepner, MD

Samuel Jones, MD

Joseph Kiernan, MD

Edward Lefrak, MD

John Maddox, MD

Paul Massimiano, MD

Robert Mesrobian, MD

Harvey Sherber, MD

Alan Speir, MD

Anne Summers, MD

ShahramYazdani, MD

Doug Cropper

Candice Saunders

To assist the group, Tom Warren, executive vice president, New Option Group, an outside professional group facilitator was engaged. Mr. Warren interviewed all of the task force members using a structured interview process and questionnaire.

In addition to the interview findings, the task force members requested the following information to assist them in forming a final recommendation:

  • What are the strategic vision and goals of the Inova Heart and Vascular Institute?
  • What are the key elements of an exclusive agreement and what is the relevant historical information on the exclusive agreement discussions?
  • What are the perspectives of the hospital, cardiac surgery and cardiology related to the advantages and disadvantages of an exclusive agreement?
  • What have other programs done (exclusive/open model)?
  • What can be learned from the Cardiology Roundtable regarding national experience with exclusive/non-exclusive agreements?

III. Summary of Findings from Research Conducted to Provide Information Requested by Task Force Members

A.Summary of Interview Findings conducted by Tom Warren:

New Options Group conducted thirty minute, face to face or telephone interviews with the following doctors: Assefi, Edmiston, Francis, Hepner, Jones, Kiernan, Lefrak, Maddox, Massimiano, Mesrobian, Sherber, Speir, Summers and Yazdani. This group has over 252 years in practice and 218 years of Inova experience and identified with one of the following groups: ‘Other’ Medical Staff, Cardiologist, or Cardiac Surgeon. In addition, we spent time with Candice Saunders, and Doug Cropper (Administration).

The expected outcome of the dialogue was to increase the understanding of the current issues to be addressed by the task force.

Generally, the following questions were asked to achieve the stated outcome.

1.Think back through your career in the heart program. Locate a moment that was a high point, when you felt the program performed really well. Describe what made the situation possible.

2.Knowing what you know about Inova Fairfax Hospital and Inova Fairfax Hospital for Children’s heart program today rate the following statement:

Today Inova Fairfax Hospital and Inova Fairfax Hospital for Children’s heart program is an industry leader. Strongly Agree (6) – Agree (5) – Slightly Agree (4) – Slightly Disagree (3) – Disagree (2) – Strongly Disagree (1). Why did you rate the program the way you did?

3.What do you value most about being a part of this program? Why?

4.What do you wish could be different? Why?

5.Describe a time in this program when you observed an extraordinary display of collaboration between the members. What made that collaboration possible?

Interview Results:

All four groups clearly articulated the primary and most critical issue as: the need to improve trust andcommunication between the groups. In addition, all agreed that the Inova Heart Program, specifically cardiology and cardiac surgery, provides excellent patient care and outcomes across the program; they described the program as progressive and efficient and there is “not much you can’t get done here.” While there are concerns, all felt the physicians get what they need for their patients. In response to question 2 they rated the program overall 4.8 out of 6.

All concurred that in order to move the heart institute forward there must exist a high level of truth and transparency from all parties involved, a collaborative effort starting immediately, improved communications and data on models that work for the best patient outcomes.

Cardiac surgeons and cardiologists voiced concerns over how to improve research for the Institute. However, their perspectives differed in that the cardiologists spoke of a concern for compensation while the surgeons are concerned that the cardiologists do not have the section infrastructure to facilitate research.

Lack of cohesiveness of the Cardiology Section came up frequently as a concern by all parties interviewed. The group expressed concerns over the cardiologists’ inability to speak with one voice and to develop and articulate a clear unified section plan in support of the Institute.

The cardiologists and other medical staff spoke of a potential “slippery slope,” threatening the private practice model enjoyed at Inova Fairfax Hospital. In addition, both groups felt the cardiovascular surgeons treat the rest of the medical staff with indifference. Both spoke of a lack of equity in benefits provided by the hospital as well as a perceived lack of physician input in decisions that shape their sections.

The cardiologists feel disengaged from administration, who seem to favor and grant more time, resources and access to the cardiac surgeons.

B.What are the strategic vision and goals of the Inova Heart and Vascular Institute?

The following vision and goals were developed as part of the Inova Heart and Vascular Institute business plan in 2001.

Mission:

To provide quality care and to improve the health of the diverse communities we serve.

Vision:

The Inova Heart and Vascular Institute will achieve distinction as a top ten program nationally through:

  • Unsurpassed clinical quality and patient care service
  • Exceptional ease of use
  • Unmatched comprehensive and compassionate care for all
  • Integration of leading technology and clinical care
  • National recognition for research and education

Goals:

Medical Staff Relationships

Create an environment that is responsive to physicians needs and supports a positive working relationship.

Marketing and Referral Development

Achieve 26 percent growth (over 2001 volume) in cardiac discharges by 2006.

Operational Excellence and Facility

Create a superior patient care model that incorporates patient and clinician ease of use (access and flow) and delivers the best possible clinical outcomes.

Technology

Become an early adopter of state-of-the-art clinical and state-of-the-market information technology to obtain a competitive advantage through advancements in outcomes, access, and communication.

Research

Become a top-tier site for multi-center trials, a preferred site for pharmaceutical and device trails, and originator of clinical research protocols.

Education

Create exceptional educational opportunities and symposia that improve physician and clinician expertise and become a vehicle for regional and national visibility.

Fundraising

Establish a fundraising committee to pursue donations to fund research and new

Program development.

Wellness

Offer a coordinated cardiac prevention and education program to the community.

Workforce

Build a dedicated cardiac workforce through recruitment, development, recognition, and retention of superior employees.

C. What are the key elements of a proposed exclusive agreement and what is the relevant historical information on the exclusive agreement discussions?

Historical Information

  • CTSA restarted the cardiac surgery program at Inova Fairfax Hospital in the fall of 1977. Edward Lefrak, MD, was the founding member of CTSA
  • Currently there are 11 cardiovascular surgeons, all members of CTSA
  • CTSA has practice locations at Fairfax, Alexandria, Arlington, and Bethesda Naval Hospitals
  • Services offered include comprehensive cardiac surgery for neonates, children and adults, vascular and thoracic surgery and involvement in state-of-the art procedures, e.g.,

Heart and lung transplant

Robotic heart surgery

Left ventricular assist devices

Minimally invasive approaches to heart surgery

Thoracic surgery – not part of exclusive contract

Vascular Surgery – not part of exclusive contract

Transmyocardial laser revascularization

Complex thoracic aortic surgery

Ross procedure

Maze procedure

Key Elements of a proposed Exclusive Agreement

General:

  • Scope of exclusive agreement: cardiac surgery (does not include vascular or thoracic surgery)
  • Terms related to recruitment and retention of physicians with benchmarks for triggering recruitment of additional physicians (expansion and succession planning)
  • Provisions for the mentoring and training of new physicians – succession plan

Customer Service:

  • Standards for physician access and availability i.e. scheduling, timeliness, etc.
  • Responsiveness to referring physicians and patients in resolving clinical issues
  • Meeting attendance to provide information/education
  • Promote and comply with established service standards for patients and staff

Reducing Variability and Cost Management:

  • Write and update protocols regularly to provide guidance to staff and decrease variability in practice – standardization for care management
  • Work collaboratively with leadership and staff to plan and implement surgical services in the most effective and efficient manner
  • Monitor individual practitioner performance and assume responsibility for controlling costs and decreasing variability
  • Establish annual goals to increase efficiency and decrease costs

Quality Improvement and Physician Performance Review:

  • Establish a clear plan for orienting and monitoring all new physicians in the group
  • Meet or exceed national benchmarks with outcome indicators
  • Peer review with quarterly reporting and evidence of appropriate actions
  • Annual independent external peer review

D.What are the perspectives of the hospital, cardiac surgery and cardiology related to the advantages and disadvantages of an exclusive agreement?

Potential Advantages:

  • Facilitates clinical management and efficiency
  • Attempts to improves quality of care outcomes
  • Provides consistent peer review efforts with action plans
  • Ensures availability of services to all hospital patients
  • Fosters joint development of physician and staff recruitment and retention plans, based on national benchmarks and programmatic needs
  • Leads and participates in hospital committees and planning efforts
  • Avoids political issues of multiple groups
  • Oversees and supervises the teaching program
  • Ensures physician succession planning
  • Leads clinical pathway development and outcome research
  • Participates actively in quality and utilization management programs
  • Facilitates communication
  • Takes an active role in cost management and vendor relations
  • Simplifies and streamlines decision making
  • Can include an effective non-compete provision in contract
  • Relationships are performance based, with continued pursuit of excellence (“raising the bar”)
  • Provide mechanism to promote communication and transparency

Potential Disadvantages:

  • Less incentive to focus on customer service
  • Less incentive to be aggressive in keeping up with the market needs
  • Lack of incentive to continue to recruit and retain
  • Less motivation to add new skills
  • Group issues and problems with physician recruitment, retention or quality of care directly affect the hospital
  • Potential conflict with cardiology groups who may want to employ cardiac surgeons
  • Patient volume for the hospital is dependent on the quality of the exclusive group and their relationship with referring physicians
  • Implementation of an exclusive agreement may be difficult to dissolve

E.What have other programs done (exclusive/open model)?

David Ashman, an internal consultant, added to benchmark information the collection of which began two years ago. Data was collected from interviews with hospitals listed as Solucient Top 100 Cardiovascular Hospitals and U.S. News and World Report Top 50 Heart and Heart Surgery Centers. Best practice calls to health systems with large cardiac programs were conducted and data from the Healthcare Advisory Board (HCAB) was also used as a resource. Key consideration were hospitals with a cardiac program similar in size and scope to Inova Fairfax Hospital. The findings from the interviews are summarized in an attachment.

Summary of Benchmark Research:

  • After reviewing the benchmark research, task force members concluded that a program can achieve distinction and excellence in many different ways. We talked with organizations that had exclusive agreements for cardiac surgery only, exclusive agreements for cardiac surgery and cardiology as well as open staff models.
  • Overall, administrators contacted a who had an exclusive agreement for cardiac surgery noted that exclusivity in their institution has proved to be beneficial for the hospital’s open heart surgery program:
  • Increased efficiencies / standardization of care from exclusive agreement model
  • Improved clinical outcomes
  • Many of the hospitals received initial push back from cardiologists related to exclusive agreements
  • No major legal issues have arisen from exclusive arrangements
  • Key success factor for hospitals – maintaining an open cardiology department

Suggestions from centers about exclusive contracting with cardiac surgeons or cardiologists

  • Anticipate future needs of the hospital and physicians
  • Succession Planning
  • Growth
  • Services offered
  • Evaluate the exclusive group’s performance during contract renewals
  • Quality
  • Growth
  • Cost
  • Patient Satisfaction
  • Maintain an open cardiology department
  • Do not hinder access to hospital services or to other specialties
  • Establish process for external peer review

IV. Conclusions

Task Force members represented had a broad range of opinions and perspectives about exclusive contracts, in general and specifically about an exclusive agreement for cardiac surgery. Following are the conclusions drawn by the task force:

  1. After reviewing the benchmark research, task force members concluded that a program can achieve distinction and excellence in many different ways. Further, they agreed that pursuing an exclusive contract needs to align with the overall strategy of the program and the market conditions of the location.
  1. The task force also concluded that quality is not an issue with the present cardiac surgry group; rather there is an acute need for a forum to foster ongoing communication.
  1. The task force concluded that routine meetings of the cardiologists, cardiac surgeons and administration are needed to facilitate dialogue on clinical and business outcomes, patient satisfaction, adoption of new technology/procedures and performance metrics related to the vision of achieving distinction as a top ten heart and vascular institute.
  1. Based on the overall strategic vision and goals of the new Inova Heart and Vascular Institute, administration believes that an exclusive agreement for cardiac surgery will help Inova continue to create a superior patient care model that delivers the best possible clinical outcomes.
  1. The cardiologists identified numerous issues about their relationships with administration, cardiac surgery and other groups. Concerns about relationships amongst the cardiologists as a group were discussed and the task force recommended that the issues identified be addressed through the newly formed Cardiology Council.
  1. Task force members agreed that the meetings with the open discussions have fostered a better understanding of the facts around a potential exclusive agreement for cardiac surgery and that the open discussions must continue between administration, cardiac surgery and cardiology.
  1. The task force concluded that the present cardiac surgery service works. Nevertheless, both administration and the cardiac surgeons are concerned about the erosion of cardiac surgery volumes related to the availability of less invasive therapies to treat heart disease. The cardiac surgeons are concerned that decreasing cardiac surgery volumes will compromise their ability to support the comprehensive services they now provide. They discussed that they can afford to provide services like pediatric cardiac surgery and heart/lung transplant as part of their overall commitment to the program despite the financial burden associated with these programs because adult volumes help support these programs.
  1. The cardiologists on the task force remain concerned that implementation of a long-term exclusive agreement for cardiac surgery will be difficult to dissolve. They also understand that opening the cardiac surgery service may disrupt the program at a vulnerable time in light of the opening of the new heart hospital in October 2004 and the unknowns related to the cardiac surgery volumes.
  1. Based on these conclusions, a two-year moratorium on changes to the present cardiac surgery physician agreement was proposed. This would allow the administration, cardiac surgery and cardiology to continue the open dialogue and to put into place some of the changes discussed. At the end of the two-year period an assessment of the progress made will be conducted. Input will be sought from the appropriate sections and a final decision regarding a definitive exclusive agreement for cardiac surgery will be made. The task force members supported this proposal with the requirement that a work group with representatives from administration, cardiac surgery and cardiology be formed immediately to address the issues and opportunities identified.
  1. During the two-year period, every six-month update on the work group’s progress will be given to the Medical Executive Committees (MEC). At the end of the two-year period a recommendation regarding a long-term exclusive agreement for cardiac surgery will be made to the MEC.

V. Recommendations: