Reducing Costs in Coronary Artery Bypass and Heart Valve Surgeries

The operation of healthcare providers differs from that of most other businesses in three important ways:

1. The most important outcomes are not measured in dollars, but in terms of patient survival and quality of life.
2. They cannot fully control their revenues—rates are often subject to influence by HMOs, insurance companies, and Medicare/Medicaid.
3. They cannot control major components of their costs. For example, the number of staff, such as nurses, is often dictated by state or national regulations.

These factors make it imperative that healthcare providers use the best methods available that will let them improve patient outcomes while controlling the parts of the cost equation that they can control.

This article is one in a series from Strong America Now that illustrate how forward-thinking healthcare providers are using quality improvement methods to meet the dual goals of improving patient outcomes and controlling the costs.

Overview
In recent years, the University of California–San Francisco (UCSF) Medical Center has begun using quality improvement methods in key areas as a way to tackle rising healthcare costs and quality of care challenges. The cardiac surgery group applied basic quality improvement techniques to reduce unnecessary usage of a costly components of care by 19%–27%, for a total annualized savings of $1.2 million.

Problem
When UCSF's Medical Center saw that the cost per case of cardiac surgery had jumped dramatically between 2009 and 2010, they discovered that high use of blood transfusions and Factor VII (a blood-clotting agent) was a major cause. Nearly 100% of cardiac surgery patients received either blood and/or Factor VII transfusions—a rate much higher than the national average (using benchmark data). Initially, there were no common guidelines around use of blood or Factor VII for the Medical Center heart patients.

Approach
UCSF put together a cross-specialty team, including a cardiac surgeon, anesthesiologist, and Lab Medicine-hematology physician to study the problem. Together with other team members, they examined all of the protocols relating to use of blood and Factor VII transfusions for cardiac patients, and used both internal and national data to evaluate the effectiveness of different procedures. The team focused on standardizing care and documenting protocols so that all of the people who provide care to cardiac patients—and the patients themselves—understand what is expected at every stage after surgery. The development of blood and Factor VII protocols reduced variability in utilization, and reduced costs and waste.

Results
Here is a summary of results comparing a 2010 baseline to nine months of FY2011:

CHANGE FROM 2010 BASELINE TO 2011*

In addition, the Cardiac Surgery team improved the flow of the patient through the hospital and the discharge process, reducing unnecessary hospital days and achieving an overall length of stay reduction of 0.9 days/case. This made 94 beds available for new patients

Lessons Learned

• Somebody on the team had to "own" the problem. In this case, the problem of high costs and high utilization of blood and Factor VII had been known for several years before the Cardiac Surgery Nurse Coordinator became the Project lead, taking on the challenge as part of her job. Once she was committed to solving the problem, other key players (including the physicians) joined in.
• Using a multidisciplinary team, which allowed the group to build relationships and work on common goals for the improvement of care for surgical patients.
• Sharing of data and patient stories across these teams to increase transparency and effectively communicate what does and does not work in practice.
• Successful completion of the project also required:
  • Having the Heart and Vascular Surgery Patients service line director to promote program, assess financial implications and assist in overcoming barriers
  • Involvement of the three key physicians (cardiac surgery chief, anesthesiologist, laboratory medicine physician)
  • Involvement of the Patient Care Manager
  • Easy access to internal cost accounting data and external benchmarking data

Credits: Thanks to Karen Rago for her help in developing this case study.