Case H The American Heart Institute Sofia V. Agoritsas and Ann Scheck McAlearney The Case of Amanda Jones Presenting with chest pain, 60-year-old Amanda Jones was rushed from the ambulance bay of the emergency department (ED) of Fast Bay University Hospital (EBUH) to the catheterization lab. The American Heart Institute (AHI) lab team determined that Jones was experiencing an ST-segment oferation myocardial infarction (STFAII), the deadliest type of heart attack. As a result, within 30 minutes of her arrival, Jones received a percutancous coronary intervention ( PCI ), but the oceluded artery could not be opened. The cardiac catheterization lab team accelerated the protocols to fasttrack Jones for emergency cardiac bypass surgery with the cardiac surgeon on call. L.uckily, Joseph Cusimano, MID, the chief of candiac surgery, was available, and Jones was taken into the operating room (OR) within one hour. As time lost was a matter of life and dearh, it was a race against time. Collaboration among the interdisciplinary teams of the divisions of cardiology and cardiac surgery and communication among the clinical leaders throughout the AHI were eritical to Joner's survilal. Fortunately for Jones, her cardiac emergency had a happy ending. She reconered and was released a week later without brain or heart damage. What Jones didn 't know, though, was that AHI was more of a virtual institute than an actual place. Although she had been seen and treated at FBUH, the collaloration and communication that occurred croned departments, divisions, and organizational boundturics, And unfortumatchy, AHI sexecutive director Sandra Cietty was not convinced that this structure alwass pronided paticnts and their fanilics with the best carc and service quality they expected and decroed. East Bay University Hospital and the American Heart Institute Cardiac Service Line EBUH, a 700-bed teaching hospital, is one of two tertiary care facilitics within True Care Health System (IC.HSI. FBUH is the flagship hospital for adult acute care in the health system. The other acute care hespital, True Care North. was only recently acquired by TCHS and is 20 miles away from the other four main facilitics. The Children's Hospital, a pschiatric hospital, and a cancer hospital constitute the remaining three hespitals of TCHS. AHI is the cardiak service line that spans TCHS. AHI is vicued as a leading provider and pioneer in cardiac care in the region. It is led by Dr. Barry A. Mount, an interventional cardiologist. AHI prowides adult cardiac care throughout the state and includes a staff of 50 full-time cmplored cardiologists and cight cardiac surgeons, five of whom primarily work out of FBCH rsee Evhibits III.8 and 111.9). The AHI senice line alvo indudes six close-to-home cartik outreach clinies that are part of ICHS's ambulatory carc network: this network spans the suburbs anound the five-hospital health system. AHI has been listed nationally by leading organizations stch as Health.

1. Case H The American Heart Institute Sofia V. Agoritsas and Ann Scheck McAlearney The Case
of Amanda Jones Presenting with chest pain, 60-year-old Amanda Jones was rushed from the
ambulance bay of the emergency department (ED) of Fast Bay University Hospital (EBUH) to
the catheterization lab. The American Heart Institute
(AHI) lab team determined that Jones was experiencing an ST-segment oferation myocardial
infarction (STFAII), the deadliest type of heart attack. As a result, within 30 minutes of her
arrival, Jones received a percutancous coronary intervention ( PCI ), but the oceluded artery
could not be opened. The cardiac catheterization lab team accelerated the protocols to fasttrack
Jones for emergency cardiac bypass surgery with the cardiac surgeon on call. L.uckily, Joseph
Cusimano, MID, the chief of candiac surgery, was available, and Jones was taken into the
operating room (OR) within one hour. As time lost was a matter of life and dearh, it was a race
against time. Collaboration among the interdisciplinary teams of the divisions of cardiology and
cardiac surgery and communication among the clinical leaders throughout the AHI were eritical
to Joner's survilal. Fortunately for Jones, her cardiac emergency had a happy ending. She
reconered and was released a week later without brain or heart damage. What Jones didn 't know,
though, was that AHI was more of a virtual institute than an actual place. Although she had been
seen and treated at FBUH, the collaloration and communication that occurred croned
departments, divisions, and organizational boundturics, And unfortumatchy, AHI sexecutive
director Sandra Cietty was not convinced that this structure alwass pronided paticnts and their
fanilics with the best carc and service quality they expected and decroed. East Bay University
Hospital and the American Heart Institute Cardiac Service Line EBUH, a 700-bed teaching
hospital, is one of two tertiary care facilitics within True Care Health System (IC.HSI. FBUH is
the flagship hospital for adult acute care in the health system. The other acute care hespital, True
Care North. was only recently acquired by TCHS and is 20 miles away from the other four main
facilitics. The Children's Hospital, a pschiatric hospital, and a cancer hospital constitute the
remaining three hespitals of TCHS. AHI is the cardiak service line that spans TCHS. AHI is
vicued as a leading provider and pioneer in cardiac care in the region. It is led by Dr. Barry A.
Mount, an interventional cardiologist. AHI prowides adult cardiac care throughout the state and
includes a staff of 50 full-time cmplored cardiologists and cight cardiac surgeons, five of whom
primarily work out of FBCH rsee Evhibits III.8 and 111.9). The AHI senice line alvo indudes six
close-to-home cartik outreach clinies that are part of ICHS's ambulatory carc network: this
network spans the suburbs anound the five-hospital health system. AHI has been listed nationally
by leading organizations stch as Healthgrades as a top-ranking cardiac progeram in the Enited
States, hut ir has not yer been ranked as a top program in t'..S. Nirus e- Ilorld Repourt.

2. The mission of AHI is to provide world-class, comprehensive cardiac care, to advance cardiac
rescarch, and to promote medical education in a fiscally responsible manner. Its vision is to
become a premier center of excellence in cardiovascular medicine in the United States.
Cardiology and cardiac surgery are to be coordinated in an integrated and seamless delivery
system. The AHI's goals and guiding principles are - to foster clinical leadership and clinical
expertise in high-quality cardiac care, - to promote a patient-centered care environment and a
culture of excellence, - to develop and implement evidenced-based guidelines that are
measurable and outcomes driven, - to provide patients with appropriate education to empower
them and their families to participate in their clinical decision making and selfmanagement, and -
to create marketing initiatives that will brand the identity of AHI.
AHI Structure AHI is, in practice, a virtual service line, requiring synergistic cooperation from
all TCHS cardiac services to realize its mission and achieve its goals (see Fxhibit 111.101 .
Across AHI the involved cardiac services include general and interientional cardiology:
clectrophyiology; the congestive heart failure (C.HF) program; cardiac rehabilitation; and
cardiac surgery; including cardiac bypass surgeri, the minimally invasive valse surgery program.
robotics surgery, the endowacular aortic repair center, and heart transplant. The main divisions
that constitute the AHI service line are cardiology and cardiothoracic surgery. These divisions
are embedded within traditional departmental structures within the departments of medicine (see
Exhibit III.11) and surgery tsec Exhibit III.121. As a result, budgetary control of the divisions of
cardiology and cardiothoracic surgery are maintained through their departments. However, AHI
service line profit and loss statements and summary of statistics reports isee Fahibit III.13) are
revicued monthly by an. AHI cardix advisory board. Furthermore, marketing activitics
incorporate advertiving for cardiology and cardiothoracic surgery under the AHI virtual seriice
line structure, despite the department of onigin.
"Physician Ambulatory Practices includes outreach elinics.
HIBIT III.13 Summary of Statistics (Includes East Bay University Hospital and True Care North
Hospital)
XHIBIT III.13 Summary of Statistics (continued)
Leadership Challenges for the AHI Service Line The executive director of AHI, Sandra Getty,
BSN, RN, MIBA, is responsible for service line business development and serves as the liaison
for cardionascular programs. She previously worked as the nurse manager in the catheterization

3. lab with Dr. Mount 20 years ago and played a major part in helping the division to become
filmless. Since then, Getty has established an electrophysiology program, including an atrial
fibrillation center and a congestive heart failure program. In her current role she is responsible
for operational leadership and review of compliance activities, coordination of operations and
budget formation for all cost centers (except for cardiothoracic surgery), capital improvements,
and expansion planning, including transition details. Getty has also been responsible for the
acquisition and derelopment of the community outreach centers through a serics of purchases of
group practices; as a result, multiple physicians are fully employed by the healtheare system.
Now, she is leading on-boarding efforts for the new community physician practices, hoping to
facilitate seamless transitions and maintain efficiencies in processes and care coordination. Cictty
has a key responsibility to make sure that all of the programs within the cardiovascular service
line are collectively marketed under the AHI brand. In addition, all the nurse managers and
practice administrators in the cardiothoracic intensive care unit (CTICL?), cardiac intensive care
unit (C.CU), and step-down and telemetry units report to her. Recently, she led the
implementation of an electronic health record system, including computerized physician order
entry capability for the divisions of cardiology and cardiothoracic surgery, in both the outpatient
and inpatient settings. She was also responsible for implementing the American College of
(ardiology (ACC) National Cardiosascular Data Registry, and the Society of Thoracic Surgeons-
approxed electronic databases that had been recommended to track patient outcomes. Gietty is
very eager to use the new health information techologics ( HIT) and systems to cnable tracking
of patient outcomes across the AHI service line. By far Cietty's biggest challenge is managing
relationships with phsician leadership and AHI faculty: The lack of cooperation among
physicians. partially attributable to the currently virtual organizational structure for the AHI
scrvice line, limits her cfforts to improve standardization and coordinate care across FBLH and
the TCHS-despite her success implementing HIT and data registrics.
Quality Improvement Challenges for the AHI Service Line Dr. Cusimano, chief of cardiothoracic
surgery, is considered a national leader in the area of cardiovascular quality improvement. He
was recruited two years ago from the northeast, in part because of his reputation for quality
improvement. Dr. Cusimano has been part of a consortium that includes cardiothoracic surgeons,
interventional cardiologists, administrators, perfusionists, anesthesiologists, and operating room
and cardiac ICU nurses; this consortium has been actively reviewing the management of cardiac
disease in the region to identify quality improvement opportunities. For more than 20 years, the
consortium has established and maintained registries and collectively developed ways to
continuously improve the quality, effectiveness, and costs of care in delivering interventions for
patients with cardiac disease. Dr. Cusimano has also played a national role in the Society of

4. Thoracic Surgeons (STS), the national organization for cardiothoracic surgeons; with the STS, he
has served as a key member of multiple executive committees. Since coming to EBUH, Dr.
Cusimano has tried to establish several multidisciplinary teams and process improvement
initiatives. He strongly believes in improving patient outcomes, not just as a necessary response
to increased scrutiny of programs by the state department of health but because it can also
address the current AHI problems associated with outmigration of patients and decreases in
patient volume. AHI is proud of its recent statepublished outcomes, including 2 percent mortality
in coronary artery bypass graft (CABG) surgery and a higher than 99.5 percent cath/PCI survival
rate in the catheterization lab. The improvements in CABG surgery, in particular, have been
particularly evident since the arrival of Dr. Cusimano. However, AHI still needs to focus on
reducing mortality rates associated with valve surgeries. Despite Dr. Cusimano's national
prestige and experience with quality improvement, the current cardiothoracic surgery faculty at
EBUH have not embraced the changes he has made. In fact, because all of the other EBUH
surgeons were formerly trainees mentored by the current chair of surgery, Dr. Craftman, many
are leery of the "new guy." Interestingly, several surgeons had noted that they believed there
were already too many cardiae surgeons on staff at EBUH, so they were predictably
unenthusiastic about bringing Dr. Cusimano into their group. For the past two years, Dr.
Cusimano has attempted to organize the group of cardiac surgeons. He has established multiple
teaching and quality forums-including enhancing the structure, participation, and transparency
of the morbidity and mortality conference meetings, and increasing clinic and didactic
involvement with residents and on multidisciplinary rounds. The performance improvement
meetings that review patient complications are now more structured, and processes to address
opportunities for systematic solutions on the basis of root-cause analyses have been developed.
In general, the tone of care quality review meetings has changed from a focus on faultfinding and
berating individuals for mistakes to one of collective efforts to find opportunities for
improvement. Dr. Cusimano has also worked with Dr. Mount to develop a daily conference
session for faculty from cardiology and cardiothoracic surgery during which faculty meet in the
catheterization lab to review all the operative cases against recommendations from the
ACC/American Heart Association guidelines prior to performing any surgeries. The objective of
this multidisciplinary forum is to enhance the physicians' abilities to assess risk and determine
appropriate treatments for patients in a collaborative environment. However, many of the
cardiothoracic surgeons do not consistently attend the conferences, often sending a resident
physician or phyysician assistant as their representative to present the surgical case under
consideration. In the area of HIT-facilitated clinical decision making, Getty and Dr. Cusimano
recently implemented a serics of inpatient order sets and evidence-based guidelines in the

5. CTICU, step-down, and telemetry units. As a result of this process, they also decided to
incorporate the division's monthly quality indicators into the AHI service line dashboand (see
Exhibit III.14). Unfortunately, this level of transparency in reporting quality data has not helped
improve Dr. Cusimano's reputation with his colleagues. Dr. Cusimano's lack of history with the
existing faculty and weak relationships within EBUH have limited his ability to build rolume and
a strong referral base, thereby minimizing his own clinical productivit. As a result, the surgeons
who operate the most use the newly arailable patient data to tout their own performance, further
discounting the value of Dr. Cusimano's contributions to EBUH. Overall, Dr. (isimano strives to
unite, motivate, and hold each of the independent cardiac surgeons accountable, but he has yet to
be successful in this endeavor. One issuc he has encountered is that the employment contracts of
the surgeons are not uniform in structure. Dr. Cusimano has proposed to the executive
administration that each physician receive a base salary and then be given an augmentation-or
bonus-hased on certain metrics (see Exhibit III.151. The measures would he reconciled through
the department of finance on a quarterly basis. In response to this proposal, the candiac surgeons
recently met privately with the executive administration of EBUH and the chair of surgery and
threatened to leave the organization. The administration's
reaction was to increase the salaries of these surgeons because they were afraid that a large
volume of surgical referrals and cases would be diverted to hospital competitors if this group of
surgeons left EBUH - but this reaction clearly undermined Dr. Cusimano's individual authority
within the group. Moreover, looking ahead, physicians have no direct incentive to align
themselves with EBUH's or TCHS's long-term goals, and this does not bode well for future
collaboration efforts.
Division of Cardiothoracic Surgery Compensation Model Surgeon: Quarter:
Additional Challenges for the AHI Service Line Dr. Mount and the other members of the cardiac
advisory board recognize that procedures have become less profitable in recent years. Increases
in costs combined with high utilization of costly devices, such as drug-eluting stents and
implantable cardioverter defibrillators, have contributed to this problem. Service line growth is a
perpetual struggle and is influenced by a variety of factors, including shifts in patient volume
from inpatient to outpatient treatments; competition across disciplines, such as cardiology,
vascular surgery, and interventional radiology; and the incorporation of novel technologies, such
as drug-eluting stents, that led to severe reductions in cardiac surgery volume. In addition, these
cost and growth challenges are exacerbated by additional operational and clinical issues. For
instance, AHI does not have a single budget because of its design as a virtual service line.

6. Similarly, because of the considerable variability in the particular conditions of each physician's
employment contract, expectations and the level of commitment between surgeons and AHI also
vary; only some of the cardiac surgeons are fully employed by the health system, and many of
the contracted surgeons feel lower levels of loyalty to AHI and the health system than AHI
would like to have. Finally, as is the case in most healthcare settings, internists and cardiologists
follow referral patterns based on their long-lasting relationships; because many of these
individuals trained as resident physicians together, they are inclined to refer to the colleagues
they know rather than follow AHI criteria for ordering consults or following the on-call
schedule. Geographic limitations also pose challenges to the coordination of patients for AHI.
Because the building infrastructure was built to accommodate traditional hospital departmental
structures, the cardiac surgery practices, CTICU, and operating rooms are contiguous with the
department of surgery and division of general surgery. However, these areas are distant (i.e.,
floors away) from the cardiology suites that include echocardiography, electrophysiology, the
CCU, and the catheterization labs. Without centralization of services, communication between
and among the various entities is complicated; this physical structure thus reinforces independent
silos of activities rather than fostering collaboration throughout AHI. In addition, many of the
cardiology group practices are located on different sites around campus. Way-finding for patients
is confusing, and the need to improve coordination of care is further compounded. Despite these
challenges, though, the cardiac advisory board believes that a comprehensive and highly
specialized heart institute that includes advanced programs will lead to profits down the road.
For instance, both Drs. Mount and Cusimano believe that the division of cardiothoracic
surgery needs to develop its minimally invasive valve surgery program. This need has become
especially pressing as the volume of CABG surgeries performed through AHI has plateaued; it
appears that many patients are being referred by community-based physicians to the comperitor
teaching hospital in the city rather than being sent to AHI surgeons. In comparison with the risks
associated with traditional surgery; patients benefit from minimally invasive valve surgery
because the breastbone is not split, the risk of infection and bleeding is lower, hospital length of
stay is shorter, recovery time is accelerated, and the cosmetic result of the surgery is better. A
strong minimally invasive valse surgery program at AHI would allow AHI to differentiate its
product from other hospital competitors that do not offer this surgical alternative. Strategic
Planning for AHI D)uring the spring of 2010, the executive administration of TCHS requested
that AHI conduct a strategic plan assessment for 2011-2015. Considering the market share
parameters that were analyzed-including population growth, total population size, inpatient and
outpaticnt market share, phsician supply and demand. parer mix, and the Ilerfindhal-Hirschman
Index (a measure of market concentration-capacity for growth and market prioritization were

7. identificd as primary arcas for strategic focus. Additional prioritics include the following: -
Establishing a discasc-bascd organization - Creating an outreach team - Building programmatic
infrastructure in the congestive heart failure and clectrophyisiology departments - Fxpanding the
AHI outreach clinic nctwork - Fxpanding the cardiac rehab program - 1Developing partnerships
with targeted local and regional community cardiology practices - Increasing Truc Care
Ambulatory Network referrals to AHI phyisicians - Establishing a one-stop communications
office - L'sing paticnt naxigators and outreach coordinaton to serie as the connectors between
AHII physicians, referring community-hased physicians, and paticnts Results of the strategic
planning process also highlighted the branding problem of the AHI and noted that much of the
problem could be
attributed to the virtual nature of the service line. Another problem the process identified was the
cannibalization of AHI market share that was occurring in certain practices and regions because
of redundancies in services offered and the substitutability of certain treatments. In some
instances the planning process suggested excessive outmigration from the outreach clinics, even
though they were part of the TCHS Ambulatory Network. It appeared that while the community-
based cardiologists were using their affiliation with AHI to promote their own practices, they
also reportedly felt disconnected from AHI and were afraid they would lose their own patients to
the main AHI campus cardiologists. Realizing the Strategic Vision: Moving from a Virtual
Service Line to Bricks and Mortar? The strategic planning process also introduced the possibility
of building a freestanding cardiac hospital. The case was made that the cardiac services division
was and would continue to be a pillar of revenue and contribution profits, and AHI might be able
to solve some of its current problems by moving into a freestanding center. Such a center would
be designed to support a comprehensive cardiac service line that included prevention, early
detection, disease management, and postprocedure follow-up care. The driving forces supporting
the case for developing the freestanding heart hospital included: (1) enhancing the academic
stature and branding image of the cardiac service line, (2) facilitating the implementation of a
more efficient clinical model, and (3) maximizing the ability of AHI to realize the value of the
cardiac service line. If this path were pursued, the freestanding facility would be expected to
epitomize the image and brand of the AHI, aligning AHI with its vision and helping to promote
identification of AHI as the destination center of excellence for cardiac tertiary and specialty
care. As a result, community-based AHI practices would be able to focus more on general
cardiac care. Centralizing specialized services in a single physical location would enable AHI to
(1) design care around patient needs, (2) integrate services and knowledge, and (3) create
efficiencies for disease coordination and systems processes. Costs would also be able to be
managed by leveraging economies of scale and scope. It was argued that patients would be better

8. served because all services would be centralized, and multidisciplinary advanced programs
would be available in one facility. The ultimate goal was that the physical infrastructure could
support programmatic development and internal physician alignment across the cardiac service
line-but at a cost of $100 million.
At present, AHI leadership must sort out the service line situation and the alternatives ahead.
Fortunately the clear consensus is that patients like Amanda Jones cannot sufter from poor
service or poor care quality because of issues related to problems with misaligned incentives,
poor collaboration, or inadequate coordination. 1.eadership realizes that it must continue to
provide both clinical and nonclinical staff with the resources and education tools ther need to be
able to provide the hest care possible. let introducing some of these resources and tools has
proved difficult in many circumstances. Neither the employees nor the staff should get caught up
in the challenges affecting the service line, but even under the most optimistic of circumstances,
a new building for the AHI would not be wailable until 2015. Case Questions 1. What problems
and issues result from the way AIH is currently organized: 2. How are design issues exacerbated
by power conflicts between and among physicians? 3. What are the issues that a new building for
AHI might be able to solve: What isstes might still plague AIII? 4. What would you recommend
that AHI lcadership do now? Who would you inole in making decisions about the future for
AHI?