Cardiovascular benchmarking saves hospital nearly $897,000

Get physicians to understand costs instead of charges

How do you get three groups of cardiologists, four groups of surgeons, and two groups of anesthesiologists to save big bucks through standardization — especially when they aren’t employed by your hospital? Ask Nina Styles, RN, BSN, CCM, cardiac case manager at Erlanger Medical Center in Chattanooga, TN. In less than a year, she led surgeons, physicians, and staff in saving cardiovascular services $896,992 at the 476-bed hospital, primarily by reducing lengths of stay (LOS) and utilization of ancillary costs for open heart surgery and angioplasty.

In addition to decreasing LOS by 1,085 days, decreased utilization of ancillary resources accounted for $530,606 of those savings. The improvements were byproducts of a benchmarking project to establish best practices and incorporate them into new care pathways. (For tips on reducing LOS, see story, p. 140.) Improving performance in cardiovascular services was contingent upon treating the cardiologists and surgeons as one unit rather than as individual practitioners, says Mike Phillips, assistant vice president of LBA Healthcare Solutions, an HCIA company based in Englewood, CO. He was the senior LBA consultant who performed qualitative and quantitative baseline studies at Erlanger to kick off the 1995 initiative. "Each phys-ician, along with his or her group, had to be integrated into the benchmarking process," he says.

Phillips stresses that the quickest way to appeal to a physician is by gathering and presenting credible data."If you try to win an opinion battle, you’ll lose. But remember, physicians are basically scientists, so credible data speak volumes," he says.

First, Phillips interviewed the physicians and surgeons to find out their individual practice patterns. "We also wanted to determine how responsive they were to the whole concept of care mapping and best practice because we knew they would be the key to instituting the changes successfully," he says. The interview process also helped identify physician champions — outstanding performers or leaders open to new processes.

In addition to physicians, Phillips interviewed managers of all clinical areas, including the cath lab, operating room, critical care unit, and telemetry as well as the medical and surgery units.

The interview form (up to 37 pages, depending on the department staff interviewed) included questions on the number of beds, equipment, supplies, labs, scheduling, and staffing. The data-gathering instrument is so lengthy, Phillips says, because "staff are the best source of information. "If you want to understand their units, then you must get their input," he says.

The interview form also asked managers to note what supplies they purchased and to identify any opportunity for standardization. "These are things they’ve probably wanted to do for a long time, so you build buy-in to the process by noting their suggestions," Phillips says.

Next, he used the hospital information system to determine financial and clinical data for more than 2,500 variables to compare with LBA’s national database. Major categories included patient demographics; diagnosis; LOS and cost for regular room, intermediate care, and critical care; operating room, anesthesia, and supply costs; ancillary costs such as radiology, lab, pharmacy, IV, and respiratory therapy; and total dollars per case.

Choose your project carefully

Although the LBA baseline study identified many opportunities for improvement, Phillips encouraged Styles to concentrate on those most likely to succeed and have the greatest impact, such as critical care length of stay and utilization of ancillary resources and supplies. "We believe that success builds success," Phillips explains. "To select the most appropriate projects, you need to filter the data through the material gleaned in the interviews and also get more input."

He and Styles developed a list of top 10 project improvements that seemed viable. "Of those 10, it’s best to concentrate on the top three or four because barriers will arise that you aren’t able to see in the beginning," he says.

Phillips estimates that assessing for baseline and identifying potential improvements took about 60 days. "We wanted to leave as much of the nine-month period for implementation as possible." LBA’s benchmarking data included comparisons with national facilities of similar size as well as neighboring facilities that were competitors.

Interdisciplinary teams a must

Armed with data to support the opportunity to improve, Styles first formed committees to develop pathways for angioplasty and later for cardiac surgery. The team eventually used a combination of pathways collected from other institutions and improvements suggested by Phillips, whose company has helped about 80 other clients develop similar pathways.

Members who worked on the coronary artery bypass graft (CABG) care path included Styles as team leader and case manager, a surgeon, an anesthesiologist, a respiratory therapist, the operating room coordinator, a pharmacist, a perfusionist, and nurses from cardiac rehab, critical care, surgical ambulatory care, the cardiac-step down unit, and the cardiac surgical intensive care unit. Representatives also attended from dietary, quality improvement, and accounting. Members who worked on the percutaneous transluminal coronary angioplasty (PTCA) path included Styles, two cardiologists, and nurses from the cardiac step-down unit, the cardiac rehab unit, cardiac cath lab and ambulatory care center, dietary, accounting, quality improvement, pharmacy.

"We invited the accounting representative because we knew we needed help in changing our mind set from patient charges to cost," Styles says. "For all team members, it was an eye-opening experience to look upon the hospital as a business."

The number crunching also helped physicians to agree on standardizing supplies, she notes. "Oftentimes they didn’t realize how much something costs. After they saw the comparisons [of one type of supply to another], we would ask, ‘Will this catheter do the same job for $200 less?’ If the answer is yes, we can buy in bulk and get a better price."

A CABG subcommittee of operating room staff headed by Terri Sentill, RN, CNOR, clinical cardiothoracic operating room coordinator for cardiovascular therapy, negotiated standardizations for cannulaes, tubing packs, open heart packs, sutures, filters, locks, foleys, armpads, and air strips.

Eliminate unnecessary tests

A "point of care" testing system reduced the costs and increased inefficiencies even further. "We used to have blood work done right before bringing the patient out of the operating room and then again when they were on the critical care unit," Styles explains. "Now we don’t repeat them." (A couple of tests that can’t be done in the operating room must be done in critical care, she notes.) Those changes by the subcommittee save about $410,606 annually, Styles estimates. (See savings breakdown, above left.)

The PTCA team saved about $120,000 by renegotiating the costs of balloons, using a target price of $350 each, Styles says. Also, not having a full operating room team standing by after hours saved more than $31,000. "If the cardiologist considers the case to be a high risk, a perfusionist does stand by," she says.

To spark ideas of other cost-saving opportunities that did not affect patient outcomes, the CABG committee studied pathways in the Southeast (such as those at Vanderbilt University Hospital in Nashville) as well as those from West Coast hospitals (such as Scripps Medical Center in La Jolla, CA). "We wanted a comparison for managed care," Styles explains.

Standardize whenever possible

They found that costs in radiology, EKG, lab, and blood bank could be decreased by ordering tests only when physicians determine them absolutely necessary. "Rather than doing a chest X-ray each day for three days, we do one when the patient comes out of the operating room for line and tubing placement and another on the second post-op day," says Styles. (See lab test utilization chart, above left.)

The PTCA team also took a hard look at costs and instituted standardizations that resulted in the following savings:

Cardiac cath lab and supply costs dropped by 28.5%. Linda Stanley, RN, cardiac cath lab manager, standardized utilization of balloons and guides and renegotiated contracts with vendors. "These supplies are a real cost generator," she says.

Ancillary costs decreased 24.8% by reduc-ing the amount of lab work and frequency of EKGs.

Contrast medium utilization per case decreased by 75cc per interventional case and 25cc per diagnostic case. "This was the minimum amount that resulted in maximum organ visibility," Styles says. "The vendor conducted a contrast management system, which helps us learn to be more conservative."